Combined Power Point Presentation for URAC Medical Home

Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN

Moderator

Presented by

How To Implement a Medical Home: Strategies for Providers, Payers and Involved Practitioners

Program Objectives• Define the purpose, goals and outcomes of the Patient

Centered Health Care Home.• Learn how providers can successfully implement

the PCHCH model.• Discover practical strategies for reimbursement and

incentivizing (from the payer side).• Explore the challenges facing both payers and providers

in setting up a successful medical home.• Explain the roles of healthcare team that make up the

patient centered health care home, including case managers, the leaders in care coordination.

Continuing Medical Education

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Science Care and Dorland Health. Science Care is accredited by the ACCME to provide continuing medical education for physicians.

• Science Care designates this activity for a maximum of 1.5 AMA PRA Category 1 Credits(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Continuing Education Credits (cont.)• Nurses: This program is approved for 1.5 contact hours for nurses by Commonwealth

Educational Seminars (CES). As an APA approved provider, CES programs are accepted by the American Nurses Credentialing Center (ANCC). Every state Board of Nursing accepts ANCC approved programs except California and Iowa. However, CES is also an approved Continuing Education Provider by the California Board of Registered Nursing, (Provider Number CEP 15567) which is also accepted by the Iowa Board of Nursing

• Certified Case Managers: This program is approved for 1.5 contact hours for case managers through the Commission for Case Manager Certification.

• Disability Management Specialists: This program is approved for 1.5 contact hours through the Certification of Disability Management Specialists Commission.

• Social Workers: This program is approved for 1.5 CE hours for Social Workers. Commonwealth Educational Seminars (CES) is approved as a provider for Social Work Continuing Education (ACE Provider #1117) by the Association of Social Work Boards (ASWB, 400 South Ridge Parkway, Ste B, Culpepper, VA 22701) www.aswb.org. ASWB Approval Period: 10/6/09-10/5/12.

• Psychologists: Commonwealth Educational Services (CES) is approved by the American Psychological Association to sponsor continuing education for psychologists. Psychologists attending this program receive 1.5 CE hours credit. CES maintains responsibility for this program.

• Licensed Mental Health Counselors/Certified Counselors: Commonwealth Educational Services (CES) is recognized by the National Board for Certified Counselors to offer CE credit. (#5596). The program is approved for 1.5 CE hours credit. We adhere to NBCC Continuing Education Guidelines.

Faculty/Disclosures• Dr. Laura Long, MD, is Vice President of Clinical Quality

and Health Management for Blue Cross and Blue Shield of South Carolina. Dr. Long reports she has no relevant financial relationships to disclose

• Jennifer O’Donnell, MHA, is the Director of Provider Services at Palmetto Primary Care Physicians. Discloses that she is a speaker and consultant for Roche Diagnostics.

• Faye Martin Liner, BS, is a Case Manager for Palmetto Primary Care Physician’s Patient Centered Medical Homes Program. Ms. Liner reports she has no relevant financial relationships to disclose

Questions for the Faculty

Please feel free to send in any questions you have via the chat session during the presentation.

The faculty will answer your questions at the end of the program.

Smarter benefits. Better health.

How to Implement Medical Home Strategies for Providers, Payers & Involved PractitionersLAURA LONG, M.D., M.P.H.VICE PRESIDENT, CLINICAL QUALITY AND HEALTH MANAGEMENT

September 27, 2011


Provider incomes linked to volume and intensity

Assumption that more care is better care and reductions = rationing

Poor continuity of care/lack of accountability for quality

Pay for improved clinical outcomes

Engage consumers on risks/benefits of treatment options. Modify benefit designs to increase use of high value services.

Provide measures of clinical outcomes and cost to physicians and patients.

Delivery System Reform Now vs. the Future?


















The Triple Aim


Innovative care redesign» Population based and patient centered

Quality based incentives» Drive evidence based practice and outcomes

Reimbursement redesign» Align incentives to support model

Transparent and measurable outcomes» Provide ROI for employers/engagement for members

Patient-Centered Medical Home (PCMH)


Patient-Centered Medical HomeWhat is it?

7 Joint Principles

Source: “Joint Principles of a Patient-Centered Medical Home,” Adopted March 2007 by: American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association

Personal Physician

Physician Directed

Team

Whole Person

Orientation

Coordinated, Integrated Care

Emphasis on Quality and Safety

Enhanced Access

Appropriate Payment Structure

Personal Physician


Harvard Medical School Analysis of Seven PCMH Pilot Programs


Patient-Centered Medical Home Demonstrations

Blue Cross Blue Shield Plan Pilots (as of January 2011)

Pilots in planning phase for 2011 implementation

Multi-Stakeholder demonstrationPilot activity in early stages of development

Pilots in progress


The BlueCross BlueShield of South Carolina Experience:

Patient Centered Medical Home


BCBSSC/BlueChoice PCMH - Criteria for Participation

Eligible practices must obtain a Level I NCQA PPC-PCMH accreditation within six months of contract execution and level II NCQA PPC-PCMH accreditation within 18 months.

Committed physician leadership Committed practice management/administrative staff A sufficient number of BlueCross and BlueShield of South

Carolina and BlueChoice patients with targeted conditions:» Diabetes» Heart failure» Hypertension


Our Journey – The Model

Provide support and guidance in assessing practice readiness for change.» Provider manual serves as a guide and quick reference tool.

Assist practice in identifying resources and obtaining low-cost vendor practice tools. » Helps practices obtain NCQA quality recognitions.» Supports practices in meeting required accreditation with NCQA-PCMH

• Level I required within 6 months, Level II within 18 months.

Establish communication channels for team-based care coordination.

Share best practices and provide ongoing training/lessons learned as additional PCMHs are implemented.


Pay For Results

Blended Payment MethodologyBlended Payment Methodology

Fee-for-

ServiceProspective

Payment

Care-based payments

Reimburses practices for rendered services• Office care

Monthly payment

Reimburses practices for additional service scope:• Case coordination• Proactive outreach• Technology and investing in infrastructure

Bonus Payment for Quality Outcomes

Reimburses practices for achieving specific quality measures through the PCMH:• Clinical processes and outcomes• Patient experience of care

Cornerstone for Success – Reimbursement Methodology


Initial Pilot Program OverviewCollaborative Partnership with Palmetto Primary Care Physicians

The Facts

• Diabetes is increasing at epidemic proportions

• 20.8 million people in U.S. have diabetes

• Two-thirds of people with diabetes die of heart disease or stroke

• Focus on disease progression reduces cx’s

• Patient self-management is critical


Measure 1st Yr Improvement4/09-3/10

2nd Yr Improvement4/10-3/11

% of members with an HbA1C test

% of members with an HbA1c test < 8

% of members with blood pressure reading

% of members with blood pressure managed to less than 130/80

% of members with LDL test

% of members with LDL test < 100

% of members with mAB test

% of members with annual eye exam

% of members with BMI measurements

Net % with improved BMI

Initial Pilot First Year Outcomes Medical Home Pilot Participants*

*Continuously enrolled participants. Outcomes measured 4/1/09 – 3/31/10


Pilot Group vs. Charleston Area Control GroupAdmissions/1000

• Baseline Year: PPCP admits/1000 7.8 % higher than Control Group.

• Intervention Year: PPCP admits/1000 10.7% lower than Control Group.


Pilot Group vs. Charleston Area Control GroupHospital Days/1000

• Baseline Year: PPCP days/1000 10.3 % higher than Control Group.

•

• Intervention Year: PPCP days/1000 36.3% lower than Control Group


Pilot Group vs. Charleston Area Control GroupER Visits/1000

• Baseline Year: PPCP ER visits/1000 13.7% lower than Control Group.

•

• Intervention Year: PPCP ER visits/1000 32.2% lower than Control Group.


Initial Pilot Financial Impact Pilot Group vs. Charleston Area Control Group

PMPM Pilot v. Control Costs Percentage Variance

Baseline (0%)

Intervention (6.5%)


Medical Home Patient Survey Physician / Patient Engagement Assessment Questions


Survey Question Based on 5-point scale N = Total number of members answering question

Medical Home Patient Survey Physician / Patient Engagement Assessment Questions


Patient Centered Medical Home Pilots: Now and Future

Palmetto Primary Care Physicians

2011 Pilots 2012 Expansion Plans

Focus: Diabetes Expand: Heart Failure Expand: Hypertension

Expand: Predictive modeling

Population:FI/ASO/FEP members

Population:FI/ASO

Population:FI/ASO

Population:FI/ASO, ?Medicaid

Approx 1,500 members including 500 state group and 350 FEP members

USC Dept of FPMackey FP

Palmetto Health affiliated practices -4 sites

Palmetto Health-8 practicesRegional Health Plus, SpartanburgSt. Francis, GreenvilleRoper, MUSC

2010 pilots


Initial Pilot Lessons Learned

Access to “real-time” clinical data is key for patient outreach and care coordination. Measure quarterly and share with MDs.

Identify and engage a physician leader at each practice site.

Effective patient education materials are critical to success. Pharmaceutical and DME companies can be excellent

resources of free, neutral materials. Education, medication management and care coordination

are key to patient compliance and improving outcomes. Patient deductibles, coinsurance and copayments can

serve as barriers to patient compliance. Transformation to Medical Home is time and resource

intensive.


You are invited to join us on the“Pathway to Patient Centered Medical Home” (PCMH)

Hear national and local experts.Hear best practices and share experiences with your peers in South Carolina.

Learn ways to begin or enhance your practice’s PCMH experience.Lunch will be provided.

When: October 15, 2011

10:00 a.m. to 3:00 p.m.Where:

BlueCross BlueShield Tower Auditorium2501 Faraway Drive, Columbia, South Carolina 29223

To register: E-mail Andrea Lance at [email protected]

We are excited and look forward to seeing you there!

Save the Date


Questions

Jennifer O’DonnellPalmetto Primary Care Physicians

Director of Provider ServicesSeptember 27, 2011

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PPCPCurrent Healthcare System

• PCMH• Case Manager (CM)• Diabetes Self Management Education (DSME)• Medication Adherence/Pharm-D• Hospital Utilization• Logistics/Tips• Summary

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• Established in 1997• Independent Physician owned LLC• 27 Clinical Sites• 86 Providers• 450 Employees• 230,000 Patients• NCQA Recognition• Patient Centered Medical Homes• Diabetic Education• Electronic Medical Record• Generic Medication

Diabetic Eye Screening Holter Monitor Event Monitor EMG (Electromyogram) Nerve Conduction Dexa Scan Echocardiogram Urgent Care Center

• Open 7 days a wk• Mon-Fri 8a-10p • Sat & Sun 10a-10p

Laboratory Services X-Ray Nuclear Stress Test Ultrasound CT Scan ABI (Ankle Brachial Index) Echocardiogram PFT (Pulmonary Function Tests) Aesthetic Procedures 24/7 Nurse Triage

Diagnostic Center

PPCP received NCQA recognition for:◦ Diabetes Recognition Program (34 providers)

◦ Heart Stroke Recognition Program (32 Providers)

◦ Patient Centered Medial Homes-Level III (19 sites) CMS recognition for PQRS AADE recognition for DSME PPCP was selected as the 1st PCMH in SC Top 20 for URAC Best Practices in 2011

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Prevalence of Chronic Diseases in US ◦ Nearly 50% of Americans live with a chronic

condition1

◦ Half of those people have multiple conditions ◦ In a national sample of 3457 adult patients,

participants received only 62% of recommended pharmacologic care2

Health costs in US growing faster than:◦ Employee wages◦ Economy at large

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45 % of Patients Are Not Receiving Recommended Care

3

Prevalence of Chronic Diseases in US •50% of Americans live with a chronic condition1

•Half of those people have multiple conditions

Care Delivered in a PCMH is consistently associated with:◦ Lower Utilization ◦ Better Outcomes◦ Reduced Mortality◦ Less Absenteeism◦ Improved Patient Compliance ◦ Fewer Hospital Admissions for Chronic Diseases

Patients using a Primary Care Physician compared to a Specialist will spend 50% less

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How many? Responsibilities? DETAILED- if you don’t ask they won’t do it

◦ Call scripts-tell them:◦ Focus on:

1) Patient Education2) Medication Adherence3) Hospital Utilization

◦ SMART goals- Specific, Measurable, Attainable, Realistic & Timely

◦ Incentivize & Challenge CMs• Process• Outcomes (in line with org goals)

• Take your time hiring• Create opportunities for CMs to develop rapport w/pt & provider• Capitalize on the provider’s personal relationship w/ the pt

• Send mail to patients from their personal provider. • Case managers should call from the patient’s personal

provider’s office.

“You’re fat and you should go on a diet.”

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• According to CDC, the 3 main risk factors for PPCP’s area

◦ Sedentary lifestyle ◦ Elevated Body Mass Index (BMI)◦ Smoking Studies have shown that DSME improves outcomes.

AADE Accredited Classes◦ Healthy Eating ◦ Being Active◦ Monitoring◦ Taking Medication◦ Problem Solving◦ Reducing Risks◦ Healthy Coping

Smoking Cessation According to the CDC, patient education on self-

managing diabetes prevents hospitalizations and for every $1 spent on these programs, health care spending is cut by $8.76.

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Medication Adherence drives P4P◦ According to a study there are 3 reasons pts aren’t

adherent8

1) They don’t understand the importance of the medication2) They are afraid of the side effects3) They can’t afford it

◦ Prior to the start date Meet with all drug companies to learn about:

Rx vouchers Patient assistance forms

Pharm D◦ offer pharmaceutical counseling to patients w/ chronic

conditions managing multiple medications

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40 to 50% of discharged patients that are readmitted w/in 30 days have not seen their PCP

CMS requires < 18% re-admits

New law directs Medicare to recover payments made for unnecessary re-admissions w/in 30 days (heart attack, pneumonia, and CHF) Reduced ◦ 1% year 1 ◦ 2% year 2 ◦ 3% year 3

PCP’s need to work closely with the CM’s/discharge planners in the Hospital to re-route patients back to their PCP

Decrease Hospitalizations= real time savings for Payers and Self-Funded groups

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Start with physician buy-in◦ Have a physician champion/medical director who is:

Respected by the group Whole-heartedly believes in PCMH Quality & Financially driven Trusts & has a good relationship with the Admin for PCMH

Creating a team◦ Admin criteria

Able to think “outside the box” Go getters Not easily stressed out Analytical Relational Strong Leadership Experience

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Training/Internal Marketing◦ Consider making mandatory training on:

Patient engagement/activation Motivational interviewing Disease education Medication adherence

◦ Pharmaceutical companies have non-branded programs for staff training

◦ Have team meetings regularly◦ Make the case managers’ meeting w/ MDs mandatory◦ Seek grant funding to cover start-up costs

Then the contracts are net profits◦ Seek economies of scale◦ Make rules for entire group

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Assess your company’s ability to fund IT projects. This will help lower costs & improve efficiencies for CMs.◦ Disease Registries◦ Health Information Exchanges◦ Patient Portals

It will be easier for larger groups to participate than smaller groups.

Implement change & monitor for CQI

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Measure everything! ◦ Track the number of appointments CMs

proactively schedule.◦ Write down success stories.

Start with physician buy-in, make case manager meetings mandatory for the entire group.

Look for values outside your system◦ Ask for claims feeds◦ Work all year◦ Watch deductibles at yr end

Remember volume is key. The greater the volume the more the fixed costs are spread out & the greater the return per patient.

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PCMH is challenging, but if you do what’s right for the patient & improve quality, reimbursement will follow.

As your group improves performance, new ways will need to come about in order to continue to have a positive impact on this population.

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The Role of the Case Manager in a Patient Centered Medical Home

Case Managers can make a major difference in outcomes

Faye Martin Liner, B.S.Case Manager, PPCP PCMH

Division

The Case Manager’s (CM) RoleIntegral in helping the patient achieve self-management of their condition.

Case Managers have a unique relationship with the patients, the doctors and other care providers, as well as with community agencies that can benefit the patient.

Proactive Scheduling10% increase in the number of visits

Improves outcomes Helps avoid acute episodic events Strengthens patient-provider relationship

Act as a liaison between the provider & the patient Ensure evidence based process & outcomes measures are met Provide personalized care to help meet individual needs & improve

patient satisfaction, for example: Educational Materials (print & online) Pharmaceutical Vouchers & Samples 10 Day Gym Passes & Discounted Memberships ADA Approved Cookbooks & Nutrition Guides Access to Some Glucometer & Strips Community Assistance Programs

CM INTERVENTION CM multi-component interventions include

self-management education home visits telephone call outreach Telemedicine client reminders.

Engage patients care self-management

Motivational Interviewing Case Managers asks questions and act as partners in

dialogue rather than giving advice or instruction.

CM makes the patient feel comfortable examining all aspects of the behavior, including their own mixed feelings about change.

Effectiveness of Motivational Interviewing According to the Harvard Mental Health Letter,

its uses are not necessarily restricted to formal counseling, and it can be incorporated into a wide range of programs for brief treatment and prevention of psychiatric disorders and other health problems.

What fits your busy schedule better, exercising one hour a day or being dead 24 hours a day?

Be Sensitive

The CM tailors discussions to patient demographic. Patient approach must be non-threatening, non-judgmental, and compassionate.You have to act sensibly,

eat the positive, eliminate the negative, and don’t mess with Mr. Sugar in between!

Mr. Dillon’s Story Age 51, correctional officer, type 2 diabetes for 12

years On worker’s compensation following inmate assault.

Recent surgery coupled with depression over job situation and physical disabilities.

Angry and frustrated over employer treatment after injuries. Patient is uncertain of job future. On anti-anxiety medication, 2 oral medications and insulin for diabetes, 4 hypertension medications and medication for insomnia. Not checking sugars as directed, poor diet, home all day alone.

A1C of 10.2. Does not exercise due to physical limitations.

Mr. Dillon’s Story

Addressing the Tipping Points: 1- Depression2-”No Big Deal”3- Inevitability4- Treatment Skepticism5- Unrealistic Plans for Action6- Poor Social contact7- Environmental problems

In discussion with the patient, clearly his situation is complicated by his diagnoses of multiple health issues, worries about his personal employment/health/financial future, and unrealistic action plans. He simply doesn’t deal with his situation.

Helping Patients Succeed is an Art!Assess the Patient’s Needs Getting him to agree he needs to

change behavior is vital.Help him prioritize He needs to check sugars as directed.

He needs an eye exam. He needs an exercise plan.

Be realistic about what will work

Don’t just suggest that he join a gym. Cost and time are often issues. Help him find alternative locations where and when he can exercise.

o Walk in the neighborhood or local Mall.o Inexpensive YMCA membership.o Join a local senior center where class is held. o Enlist a friend or spouse as a “work out” partner.o Chair exercises with exercise bands we provide.

Improving Outcomes Mr. Dillon’s A1C is now 7.4 walking for exercise greatly reduced smoking taking medication as prescribed working with an employment attorney to return

to work in a limited capacity.

Motivate the PatientClients fail to comply with medical treatment for a variety of

reasons:

o Inability to afford medications, failure to appreciate the seriousness of their condition, mental health issues such as depression, and an unsupportive family are a just few examples.

Assess the Situation

o Understand why your patient is noncompliant. Can he afford medication? Does he understand instructions? Is he depressed? Pinpointing the reason will help you find a way to your patient.

Look for warning signs that your patient may need special attention to follow the treatment regimen.

o Is she following her diet guidelines or is she gaining weight? Does she keep office appointments or is he often a no-show? Has he had multiple incidents of disease crisis? These are signs that you need to try harder to reach your patient.

Assess whether your patient is satisfied with his care.

o Unhappy patients are less likely to comply with treatment. Ask about his satisfaction with the customer service aspects of your practice as well as any issues he may have with the medical staff. Address any concerns.

Encourage Compliance, set goals, provide tools and resources “Each person has an

internal set of pros and cons that influence behavior.

Find out those factors, keep the goal in mind, which is getting patients to take their medications to make changes such as losing weight.

Auburn University (2007, July 26). Patient Compliance Improves Through 'Motivational Interviewing'. Science Daily. Retrieved September 20, 2011, from http://www.sciencedaily.com /releases/2007/07/070721194716.htm

I don’t think that is what your doctorMeant by lowering your carbs, honey

Diabetes Self-Management EducationInterventions (DSME)

Talk with the patient about attending diabetes education. Be prepared for objections and excuses!

The goals of DSME are to optimize metabolic control, prevent acute and chronic complications, and achieve an optimal quality of life, while keeping costs acceptable.

I think that went rather well for your first time

The goals of diabetes education are to ooptimize metabolic control, to prevent acute and chronic complications,and to achieve an optimal quality of life while keeping costs acceptable

Collaboration with Providers

o Building meaningful relationships with providers as part of the Medical Homes Team is vital to complete the circle of support.

o Communicate (EMR) with information discovered during patient contact. Relay concerns, questions and needs from patients.

o CM schedules follow-up visits, and lab work and message the doctor for Rx refills or other requests.

o Have regular meetings to provide data, feedback and learn provider preferences.

patients are eager and grateful for our support.

CMs reach out to community organizations that enhanced our patient support.

Any reproduction or distribution of the information presented without the prior consent of Palmetto Primary Care Physicians is prohibited.

The PCMH Team is Vital in today’s health care management

Thank You

Upcoming Events• Next Webinar: October 27, 2011: Medication Reconciliation• URAC Quality Summit XII: Navigating the New Health Care

Environment: Protecting Consumers and Delivering Value: October 4-6, 2011Chicago, IL https://www.urac.org/12thAnnualSummit/12thAnnualSummit.asp

• Dorland Care Coordination Summit: October 21, 2011 at the National Press Club in Washington DC. http://www.dorlandhealth.com/care_coordination_summit

Thank You

You will receive a ‘Thank You’ email which will contain the link to the posttest and program evaluation for those who

want to receive continuing medical and professional education credits.

Combined Power Point Presentation for URAC Medical Home

Documents

relevant financial

modify benefit

delivery system

provider incomes

centered medical

commonwealth

medical home

personal physician