The Patient-Centered Medical Home

1. The Patient-Centered Medical Home An Opportunity for Senior Living Provider Systems?

2. Impacts of An Aging Society • American society is experiencing growth in its elderly residents that is unprecedented in the history of the world • It is anticipated that by 2030 the US will have approximately 76 million residents over the age of 65 • Many experts believe that the US is wholly unprepared to meet the many complex needs of a large elderly society and that we need to steps now to address this need in the areas of: • Affordable housing for seniors • Support services related to senior living needs • Improved transportation • Significant deficits in access to healthcare for seniors • Access to quality healthcare may be the single most challenging issue facing seniors in the next 2 decades • Severe shortage of primary care physicians and geriatricians • The average 75 year old has 3 chronic conditions and takes 4 meds • Poor services to treat chronic illnesses • Fewer SNF beds available • More single households making access to care more problematic • Alzheimer’s Disease will exacerbate access to care problems • It is anticipated that 1 in 8 seniors will have Alzheimers

3. Impacts of An Aging Society • As more barriers to access to healthcare for seniors develop, it is important that we find new models for health care delivery to our senior population. • One such model of alternative health care delivery that is currently under review is the Patient-Centered Medical Home (“PCMH”). • This morning, we are going to examine the PCMH and discuss whether PCMH provides a significant opportunity for senior living providers to make a value-added contribution to the health care needs of our elderly population. DISCUSSION • PCMH. Dr. Michael Goran will provide information and background concerning PCMH. • Application to Senior Living Providers. Following Dr. Goran’s explanation of PCMH we will use the Roundtable to discuss whether the implementation of a PCMH may provide a viable strategy for senior living providers.

4. The Patient-Centered Medical Home Dr. Michael Goran

5. Impetus for Patient-Centered Medical Home (PCMH) Model Patient-Centered care is one of the key components of quality health care called for by the IOM in 2001 “The PCMH is the best opportunity for aligning physicians, patient frustration, demonstrated models for improving care, and private and public payment systems to produce the most profound transformation of the health care system in anyone’s memory.” (Robert Graham Center, November 2007) “The future of primary care is at great risk at a time when the evidence suggests that the nation needs primary care more than ever.” (American College of Physicians, 2009) Many areas of the nation are currently experiencing shortages in PCPs and unless there is fundamental change the shortage of primary care physicians will grow to 124,000 by 2025 (American College of Physicians, 2009)

6. Barriers to PCMH • Physician payment reforms are needed to adequately compensate PCPs to provide patient-focused, coordinated care and to acquire the health information technology necessary to provide such care • Traditional payment systems reward physicians for increasing volume of visits and procedures • Traditional payment systems do not provide incentives to coordinate care • And provide no mechanism for physicians to share in the savings that physician-guided care coordination activities generate • Primary care physicians require technical assistance to reorganize their practices into modernized PCMHs (A Lifeline for Primary Care, Bodenheimer, et al., NEJM)

7. What is a Patient-Centered Medical Home? “The PCMH is an approach to providing comprehensive care for children, youth and adults. The PCMH is a health care setting that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient’s family.” (Joint Principles of the PCMH, March 2007, AAFP, AAP, ACP, AOA)

8. Principles • Personalphysician—each patient has an ongoing relationship and receives continuous, comprehensive care • Physician directed medicalpractice—physician led team collectively take responsibility for the ongoing care of patients • Whole personorientation—responsible for all the patient’s health care needs including arranging care with qualified professionals for all stages of life; acute, chronic, preventive and end of life • Care is coordinated and/or integrated—across all elements of complex health care system including subspecialty care, hospitals, home health agencies, nursing homes and the patient’s community. Care is facilitated by registries, HIT and exchange of information • Quality and safety—practices advocate for their patients to attain optimal outcomes that are defined by a care planning process driven by a compassionate partnership between patient and the care team. PCMH is accountable for continuous quality improvement. Patients actively participate in decision-making and feedback. HIT is used to support optimal patient care, performance measurement, patient education and enhanced communication. Practices go through a voluntary recognition process • Enhanced access—open scheduling and new options for communication between patients and their care team • Payment reform—recognizes added value provided to patients who have a PCMH

9. History of PCMH American Academy of Pediatrics introduced the term medical home in 1967 WHO adopted basic tenets of the medical home in 1978 IOM embraced the concept of patient-centered care and the medical home in 1990 PCMH draws extensively on concepts of Ed Wagner’s Chronic Care Model (Group Health of Puget Sound)

10. Goals of PCMH Patient care will be provided through a multidisciplinary team and will be dependent on a deep understanding of the population served by the practice. (FFM Task Force 1 Report) “Integration is complex, time-consuming work; improving primary care’s performance in integrating care will involve an effort akin to that of improving safety.” (Robert Ferrer, et al.) “Rather than uncoordinated, episodic care, we need to offer care that is well organized, coordinated, integrated, characterized by effective communication, and based on continuous healing relationships.” (Eric Larson)

11. Relationship of PCMH to Specialty Physicians • PCMH model will facilitate improved communication between the PCP and the referred specialist or subspecialist • Unlike gatekeeper, PCMH will not limit appropriate referrals • PCMH will have systems in place to communicate more effectively with consultants and co-management colleagues • PCMH model will decrease inappropriate and unnecessary referrals • PCMH model provides for specialty or subspecialty practices to be the principal care physician for a subgroup of patients with complex conditions such as: • Difficult to control diabetes • Inflammatory bowel disease or hepatitis • HIV • Severe rheumatoid arthritis • Advanced heart failure • Malignancy

12. Hub of Care • PCMH is the central hub of care—the location that is responsible for the overall coordination of the patient’s care • PCMH practice must have in place the structural capability to assume the role of overall coordinator of care • Systems to track patient referrals and treatments, medications, diagnostic tests and laboratory results • Ability to communicate this information to other participating healthcare teams and to the patient • PMCH practice will have formal or informal agreements with each referred to or care co-managing specialty or subspecialty provider regarding coordination of care • PCMHs can be the primary care foundation of Accountable Care Organizations • PCMHs will deploy advanced technology such as Remote Patient Monitoring and broad band Telemedicine to improve outcomes for patients with complex and/or multiple chronic diseases

13. Defining the Medical Home (Slide from Patient-Centered Primary Care Collaborative) • Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs. Publically available information Source: Health2 Resources 9.30.08 8

14. TODAY’S CARE MEDICAL HOME CARE My patients are those who make appointments to see me Our patients are those who are registered in our medical home Patients’ chief complaints or reasons for visit determines care We systematically assess all our patients’ health needs to plan care Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet patient needs without visits Care varies by scheduled time and memory or skill of the doctor Care is standardized according to evidence-based guidelines Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care I know I deliver high quality care because I’m well trained We measure our quality and make rapid changes to improve it Acute care is delivered in the next available appointment and walk-ins Acute care is delivered by open access and non-visit contacts It’s up to the patient to tell us what happened to them We track tests & consultations, and follow-up after ED & hospital Clinic operations center on meeting the doctor’s needs A multidisciplinary team works at the top of our licenses to serve patients Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

15. Standards and Guidelines for PCMHs • NCQA is developing/testing certification program with 3 levels of recognition and 10 must pass elements • Includes measures • Access/communication • Patient tracking/registry function • Care management • Patient self-management support • E-prescribing • Test/referral tracking • Performance reporting • Advanced electronic communication • Web-based data collection tool • Scoring • Level one (must pass 5 of 10 elements at 50% and have 25-49 points) • Level two (must pass all 10 elements at 50% and have 50-74 points) • Level three (must pass all 10 elements at 50% and have 75+ points)

16. NCQA PPC-PCMH Content and Scoring **Must Pass Elements

17. NCQA PPC-PCMH Scoring Levels: If there is a difference in Level achieved between the number of points and “Must Pass”, the practice will be awarded the lesser level; for example, if a practice has 65 points but passes only 7 “Must Pass” Elements, the practice will achieve at Level 1. Practices with a numeric score of 0 to 24 points or less than 5 “Must Pass” Elements are not Recognized.

18. How Would a PCMH Be Compensated? A prospective, per patient, per month bundled care coordination component (risk adjusted for patient severity and for how advanced a practice is in HIT). The care coordination fee would also include services such as the time that physicians and their staff spend on coordinating care with family caregivers or other clinicians A fee-for-service payment for the face-to-face encounters with patients A performance-based component based on the achievement of defined quality, cost or care and patient experience measures

19. PCPCC Payment Model(Slide from Patient-Centered Primary Care Collaborative) Key physician and practice accountabilities/ value added services and tools Proactively work to keep patients healthy and manage existing illness or conditions Incentives Coordinate patient care among an organized team of health care professionals Incentives Performance Standards Utilize systems at the practice level to achieve higher quality of care and better outcomes Incentives Focus on whole person care for their patients 16

20. PCMH Activity(From Patient-Centered Primary Care Collaborative) 27 pilot programs in 20 States 8 Medicare pilots planned for 2009 44 States and District of Columbia have passed over 330 laws and/or have PCMH activity Health Reform bills propose expansion of PCMH activity As of January 2009, 28 BCBS Plan Pilots Cigna pilot in NH; Aetna has pilots in CO, ME, NY, PA, and NJ; Wellpoint has pilot in NY; UnitedHealth has pilot in AZ PPPCC in its third year has multiple stakeholders, 550 members committed to advancing PCMH concept

21. The Patient-Centered Primary Care Collaborative Examples of Broad Stakeholder Support & Participation Providers 333,000 primary care Purchasers – Most of the Fortune 500 • ACP • AAP • IBM • Ohio • AAFP • AOA • Iowa • FedEx • General Electric • ABIM • ACC • Dow • ACOI • AHI • Business Coalitions The Patient-Centered Medical Home • Microsoft • Merck & Co. 80 Million lives Payers Patients • AARP • AFL-CIO • BCBSA • Aetna • National Consumers League • United • Humana • CIGNA • Kaiser Permanente • SEIU • Foundation for Informed Decision Making • WellPoint • Geisinger

22. PCMH Results • PCMH improves access to needed care, increases utilization of preventive screenings, and improves management of chronic conditions (Commonwealth Fund) • Rigorous evaluation of 4,000 patients with diabetes, congestive heart failure, asthma and depression with care provided according to PCMH principles (RAND and UC Berkeley) • Patients with diabetes had significant reductions in cardiovascular risk • CHF patients had 35% fewer hospital days • Asthma and diabetes patients were more likely to receive appropriate therapy • NC Medicaid program saved $224M per year by enrolling recipients in a network of PCMHs (Mercer) • Denmark has organized its entire health care system around PCMHs and has the highest patient satisfaction ratings in the world and among the lowest cost per capita health expenditures (Commonwealth Fund) • Care delivered by primary care physicians in a PCMH is consistently associated with better outcomes, reduced mortality, fewer preventable hospital admissions for patients with chronic diseases, lower utilization, improved patient compliance with recommended care, and lower costs (Patient-Centered Primary Care Collaborative)

23. Pilot: Geisinger Health System

24. The Patient-Centered Medical Home An Opportunity for Senior Living Provider Systems? Larry Garcia

25. Is a Patient-Centered Medical Home an opportunity for a Senior Living Provider System? We offer the following hypotheses to the Roundtable for discussion: Offering a PCMH on the campus of a senior living provider represents an important branding and marketing opportunity for a senior living provider. Operating a PCMH, either a direct service or under a joint venture with a health care provider system, represents an important clinical and business opportunity for a senior living provider.