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PCMH Collaborative

Results from the Patient-Centered Medical Home Collaborative What They Mean and What’s Ahead for Medical Homes, Health Homes & Rural Hospitals Anne Shields, RN, MHA Washington State Department of Health. PCMH Collaborative. Collaboration of the Washington Academy of Family Physicians and DOH

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PCMH Collaborative

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  1. Results from the Patient-Centered Medical Home CollaborativeWhat They Mean and What’s Ahead for Medical Homes, Health Homes & Rural HospitalsAnne Shields, RN, MHAWashington State Department of Health

  2. PCMH Collaborative • Collaboration of the Washington Academy of Family Physicians and DOH • 32 practice teams throughout state • Two-year practice transformation journey • Practice teams elect focus on selected chronic conditions and preventive services • Collaborative concludes September 2011

  3. PCMH Clinical Measures Prevention (Quarterly) Pediatric • Well child / two age groupings • Adult • Cancer screens, tobacco cessation • Geriatric • Advanced directives, • Greater than 15 meds Diabetes (Monthly) • Improving Performance In Practice measures • American Board of Medical Specialties • Clinical outcomes • Blood sugar, BP, LDL • Utilization measures • Foot exams

  4. Blood Pressure Control • Target range: BP at 130/80 or better • Over one third of clinics report BP under control among half or more patients Current Rock Star Cheney Rockwood Medical Clinic 75% of patients in target range

  5. Cholesterol Level • Target range: LDL at or below 100 • One third of clinics have well over half of patients within target range • Half of all clinics have 47% or more at within target range Current Rock Star Seattle Polyclinic 72% of patients in target range

  6. Blood Glucose Level • Target range: HgA1c at or below 9% • One third of clinics have significant majority at or below target range • Half of all clinics have 82% or more of patients at or below the target range Rock Stars Gig Harbor Medical Clinic - 92% Medical Lake Rockwood Clinic - 95%

  7. Measuring “Homeness” & Experience • Medical Home Index • Self-assessment across six domains • Data collection in September 2009, 2010, 2011 • Patient Experience Survey • Based on CAHPS • Baseline Spring 2009 and post-survey underway • Provider Burn-out and Team Satisfaction • Data collection in September 2009, 2010, 2011

  8. Medical Home Index: At Baseline and One Year

  9. Primary Care Providers Maslach Burn-Out InventoryMeasured @Baseline and Year 1 ( N=44)

  10. Provider Team Satisfaction

  11. PCMH Cliff Note Version • “Rule of thirds” in learning collaboratives • Rock stars and early adopters • Middle of the roadsters • Non-starters • Degree of medical home implementation • Improved across the board thus far • Provider burn-out and team satisfaction • Clinical measures @ year 1 • No significant progress in prevention measures • Prevention data difficult to capture and report • Diabetes measures strong but may be flattening

  12. Rock Stars and Early AdoptersYear 1 Diabetes Measures(In alphabetical order) • Redmond Evergreen Medical Group @ Redmond • Lyndon Family Medicine • Olympic Clinic @ Shelton • Pacific Medical Center @ Seattle • Polyclinic @ Seattle • Port Orchard Medical Clinic • Rockwood Medical Clinic @ Cheney • Rockwood Medical Clinic @ Medical Lake

  13. What’s Next?After the conclusion of PCMH Collaborative • Broaden practice improvement strategies under recent DOH restructuring • Includes Perinatal Collaborative and other efforts to improve outcomes for moms, newborns, and infants • Launch local TA/training to reach and engage more providers in more care settings • Significant role for hospitals in QI • New partnerships in purchasing and delivery systems to support health reform opportunities • Quality, outcomes, and affordability aims

  14. Financing Opportunities for Medical Homes • Section 2703 of the Affordable Care Act • Health home services for Medicaid Enrollees with chronic conditions • 2011 Senate Bill 5394 • Promoting primary care health homes and chronic care management

  15. Is a health home the same thing as a medical home? • Health homes may or may not be within the walls of a primary care practice • Health homes are designed to be person-centered systems of care that facilitate and coordinate all care • Primary and acute physical health services, behavioral health care, and long-term community-based services and supports • Both models aim to improve clinical outcomes and patient experience while reducing per capita costs • Medical homes can be – but don’t have to be – the foundation for a health home

  16. ACA Section 2703 • Allows state to incorporate health home services for Medicaid patients • 90% federal matching rate for first two years • Focus on high need, high cost patients with chronic conditions, including behavioral health concerns • Focus on reducing hospital readmissions, avoiding ED visits and reducing reliance on LTC facilities

  17. Six “Health Home Services” under Section 2703 • Six newly reimbursable services: • Comprehensive care management • Care coordination and health promotion • Comprehensive transitional care/follow-up; • Patient and family support • Referral to community and social support services • HIT to link services, if applicable • Services may or may not be incorporated into a primary care clinic

  18. Who can receive2703 health home services? • Medicaid beneficiaries with: • Two or more chronic conditions (mental health, substance abuse, asthma, diabetes, heart disease, being overweight) • One chronic condition and at risk for a second or • Serious and persistent mental health condition • Cannot exclude dual eligibles • Can target individuals within a subset of specific chronic conditions, or target geographically

  19. Who can provide 2703 health home services? • Designated provider: May be physician, clinical/group practice, rural health clinic, community health center, community mental health center, home health agency, pediatrician, OB/GYN, others • Team of health professionals that link to a designated provider: May include primary care provider, nurse care coordinator, nutritionist, social worker, behavioral health professional • Health team: A “team of health care professionals” may include a nurse care coordinator, nutritionist, social worker, behavioral health professional, community health worker or other professionals deemed appropriate by the state and approved by HHS

  20. How will we measure success in implementing Section 2703? • States must track and report outcomes in avoidable readmissions, ED, SNF admissions and calculate cost savings • Designated providers must report quality measures as condition of reimbursement • Independent evaluator will survey states on impact of health home services on cost, clinical and utilization measures

  21. ESSB 5394 • Introduced by Sen. Karen Keiser to promote the adoption of primary care health homes and advance chronic care management strategies • Requires HCA to include health home services defined in Section 2703 of ACA • Requires HCA to include health home services incentives in its managed care contracts and self-insured plans • Allows HCA to prioritize health home services to enrollees with complex, high cost, or multiple chronic conditions

  22. How will we measure success for SB 5394? • State legislation generally aligned with federal reform • Outcomes in avoidable hospital, readmissions, ED, SNF admissions important • HCA to coordinate discussion with carriers regarding chronic care management and principles for effective reimbursement incentives • Role of hospitals and ED transitions is key factor • HCA required to report progress in implementation to Legislature by December 2012

  23. Hospital Transitions • 18% of Medicare discharges readmitted w/in 30 days at annual cost of $15 billion • Result of complex interactions that may include: • poor quality care or premature discharge • transitions between providers and care settings • lack of social support and follow-up care • Patient’s behavioral choices or lack of understanding of discharge instructions • Readmits more common for some conditions Heart failure and ESRD

  24. How are we doing on readmissions within 30 days? In state ranking of Medicare readmissions as % of all admits for 31 clinical conditions: • Washington State in the third quartile (50% to 75% of all admits ) • Neighboring states (OR, ID, AK) all in top 25% Data from Commission on a High Performance Health System. “State Scorecard Data Tables.” Supplement to Aiming Higher: Results from a State Scorecard on Health System Performance. The Commonwealth Fund, June 2007.

  25. Best Practices in Transition HomeWSHA STAAR Pilot Project • STAAR aims to reduce readmits by 30 percent • Key actions include: • Enhanced Admission Assessment for Post-Hospital Needs • Effective Teaching and Enhanced Learning • Real-Time Patient and Family-Centered Hand off Communication • Post-Hospital Care Follow-Up Actions from IHI Guide to Creating Ideal Transition Home (See WSHA website)

  26. Emergency DepartmentsFrequently Providing the Wrong Care at the Wrong Time • 50% of all ED visits non-emergent or avoidable • Number of emergency room visits increased 20% in a decade (96 to 115 million visits) • The cost of ED visits often 2 to 5 times greater than cost in alternate settings

  27. True or False? • Lack of primary care access is a major contributor to avoidable ED visits. • Lack of or inadequate health insurance is a major reason for recent increases in ED utilization. • Major cost savings can result from focusing on “frequent fliers.”

  28. Complex Patient Incentives andFinancial Incentives for ED Use • Recent ED visit increases in countries with strong primary care access • ED overuse across all payers and patient demographics • Some hospitals make a business case for overuse

  29. Effective Practices in ED Alternative Care PilotsDSHS / WSHA / WACMHC Collaboration • Timely and direct communication between sites • Info sharing • Well-defined proactive referral process • Pain management program • Support from DSHS Pt Review and Coordination • Care coordination • Patient advocate • Clinic/ER liaison • Community-wide education Final report due July 2011

  30. Medicaid Quality Incentives • Reducing preventable emergency department visits is one of five incentive measures • Hospital reports on ED reductions due Sept. 1, 2011 • Rate increases for qualifying hospitals in 2013

  31. Thank you!Questions or comments? Anne Shields RN, MHA Director, Practice Improvement Office of Healthy Communities Prevention and Community Health Washington State Department of Health Anne.shields@doh.wa.gov (360) 236 - 3686

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