Overview of The Patient Centered Medical Home (PCMH) Movement HRSA Office of Rural Health Grantee Partnership Meeting September 2, 2009 - PowerPoint PPT Presentation

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Overview of The Patient Centered Medical Home (PCMH) Movement HRSA Office of Rural Health Grantee Partnership Meeting September 2, 2009


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Title: Overview of The Patient Centered Medical Home (PCMH) Movement HRSA Office of Rural Health Grantee Partnership Meeting September 2, 2009

Overview of The Patient Centered Medical Home
(PCMH) Movement HRSA Office of Rural Health
Grantee Partnership MeetingSeptember 2, 2009
  • Shari EricksonSenior Associate, Center for
    Practice Improvement Innovation

  • Millions of our citizens do not now have a full
    measure of opportunity to achieve and enjoy good
    health. Millions do not have protection or
    security against the economic effects of
    sickness. The time has arrived for action to help
    them attain that opportunity and protection.

President Harry Truman Text from a speech he
delivered to a joint session of Congress in 1945
  • So let there be no doubt health care reform
    cannot wait, it must not wait, and it will not
    wait another year.

President Barack Obama Text from a speech he
delivered to a joint session of Congress ,
February 24, 2009
The Case for Health Care Reform Case for PCMH
  • Poor access to care, especially for the uninsured
  • Rising costs and gaps/variation in quality of
  • Increase in chronic conditions
  • Need for better care coordination
  • Dysfunctional payment system rewards volume,
    face-to-face services
  • Impending collapse of primary care
  • Purchasers demand for accountability and
  • United States is lagging internationally

Presentation Outline
  • Overview of the patient-centered medical home
  • Joint Principles
  • PCMH recognition program
  • Features of a PCMH practice
  • Growing support for the PCMH model
  • Efforts to test the PCMH model
  • Additional Activities Underway and in the Future

High-Level Medical Home Overview
  • ACP and others refer to medical home as the
    Patient Centered Medical Home
  • Strengthening the physician-patient relationship
  • Getting patients the care they want and need when
    they need it
  • Vision of primary care as it should be
  • Framework for organizing systems of care at both
    the micro (practice) and macro (society) level
  • Model to test, improve, and validate
  • Important component of more comprehensive reform

Evolution of the PCMH Joint Principles
  • ACP, American Academy of Family Physicians
    (AAFP), American Academy of Pediatrics (AAP), and
    American Osteopathic Association (AOA) have
    similar positions in promoting PCMH
  • ACP, AAFP, AAP, and AOArepresenting 330,000
    physiciansestablish PCMH joint principles in
    March 2007 to provide standard definition of
    delivery model and describe the environment
    necessary to support it
  • These joint principles guide the collective
    actions of the organizations to further develop,
    promote, and test the PCMH

Joint Principles
Team-based care NP/PA RN/LPN Medical
Assistant Office Staff Care Coordinator Nutritioni
st/Educator Pharmacist Behavioral Health Case
Manager Social Worker Community resources DM
companies Others
  • Personal physician in physician-directed practice
  • Whole person orientation
  • Coordinated care, integrated across settings
  • Quality and safety emphasis
  • Enhanced patient access to care
  • Supported by payment structure that recognizes
    services and value

Joint Principles-Recommended Supporting Payment
  • Payment model is intended to facilitate and
    sustain improved care delivery and provide a mix
    of incentives to optimize patient care
  • Bundled, severity-adjusted care coordination fee
    paid on a monthly basis for the following
  • The physician and non-physician clinical staff
    work required to manage care outside a
    face-to-face visit
  • The health information technology and system
    redesign incurred by the practice
  • Continued per-visit, fee-for-service (RBRVS)
  • Performance-based bonus payments based on
    evidence-based measures of care

How do you Know a PCMH When you See One?
  • Process needed to recognize practices that have
    and use the capability to provide
    patient-centered care
  • Practice recognition provides purchasers
    (employers, government) and patients with
    prospective assurance that the practice has
  • National Committee on Quality Assurance (NCQA)
    announced a voluntary recognition process based
    on its Physicians Practice Connection (PPC)
    module, the PPC-PCMH in January 2008
  • ACP, AAFP, AOA, and AAP helped NCQA develop the
  • Other entities can develop PCMH recognition
  • Recognized PCMHs would also be accountable for
    quality of care by reporting on evidence-based
    clinical and patient experience measuresprovides
    retrospective assurance

NCQA PPC-PCMH Recognition Module Major
  • Access Communication
  • Patient Tracking Registry Functions
  • Care Management
  • Patient Self-Management Support
  • Electronic Prescribing
  • Test Tracking
  • Referral Tracking
  • Performance Reporting Improvement
  • Advanced Electronic Communication
  • Each standard contains sub-elements

Scoring Building a Ladder to Excellence
Level 3 75 Points 10/10 Must Pass
Level 2 50-74 Points 10/10 Must Pass
Level 1 25-49 Points 5/10 Must Pass
Increasing Complexity of Services
Key Points for Level 1 PCMH
  • Does not require electronic health record
  • Will require registry tracking functions
  • Emphasis is on providing better care through
  • Access to care
  • Organization of office structure processes
  • Enhancing patient self-management addressing
    health literacy issues
  • Introduction of evidence-based guidelines,
    measurement quality improvement

Level 2 ? Level 3
  • Advanced access options for patients
  • Electronic health record
  • More, and more complex care coordination and
    patient support
  • Robust population management
  • Advanced reporting and quality improvement
  • Additional technology solutions

More Features of a PCMH Practice
  • Uses each team member to his/her highest
  • Supports cultural competency training for
    clinical team
  • Understands health literacy
  • Establishes connections to the community and
    available resources
  • Provides extensive self-management support
  • Engages a Patient/Family Advisory Group

More Features of a PCMH Practice
  • Provides individualized written care plans and
    monitors adherence to plan with patient/family
  • Assesses barriers to adherence and initiates
    plans to overcome them
  • Collaborates with other physicians institutions
    to insure timely access to health information
  • Manages transitions of care seamlessly

NCQA Recognition Activity
  • 149 practices have received recognition across 17
  • 46 Level 1
  • 4 Level 2
  • 50 Level 3 (12 of 75 in practices of 1-2
  • Practices more likely to seek recognition
    when/where tied to reward
  • Smaller practices (in number of physicians)
    somewhat more likely to be Level 1 larger
    practices somewhat more likely to be Level 3

Source NCQA, as of June 12, 2009
Growing Support for the PCMH Model
  • Many supporting organizations have come together
    through the Patient Centered Primary Care
    Collaborative (PCPCC), which formed in 2007 and
    has over 560 member organizations, including
  • Organizations representing over 350,000
    physiciansincluding ACP and other primary care
    societies, American College of Cardiology,
    American Academy of Neurology
  • Organizations representing over 50 million
    employees, including large employer umbrella
    groups, and individual companies such as IBM,
    General Motors
  • All major health plans
  • CVS Caremark, including MinuteClinic
  • Consumer organizations including AARP
  • Bridges to Excellence
  • State governments and public health departments
  • PCPCC organizations attest to their support of
    the PCMH Joint Principles, including the belief
    that the PCMH will improve health of patients
    and the viability of the health delivery system,
    and support a better payment model to facilitate

PCPCC on the web http//www.pcpcc.net
Overview of PCPCC Activities
  • Four Collaborative Centers
  • Multi-Stakeholder Demonstrations
  • Public Payer Implementation
  • Health Benefit Redesign and Implementation and
  • eHealth Information Adoption and Exchange
  • Events
  • Two stakeholder meetings per year
  • One national summit
  • Weekly calls
  • Collaborative center calls
  • Products (all available free of charge)
  • Purchasers Guide to the PCMH
  • IT Resource Guide
  • Consumer Materials
  • PCMH Pilot Compilation

Overview of PCPCC Activities (cont.)
  • The Purchasers Guide (http//www.pcpcc.net/content
    /purchaser-guide) Aims to address What is the
    PCMH? Why should employers/purchasers support
    it? What strategies and action steps should
    employers/purchasers consider now?
  • Meaningful Connections IT Resource Guide
    ns-it-resource-guide) Identifies the
    capabilities and functionalities of eHealth
    applications that experts consider crucial to
    support PCMH.
  • Engaging the Consumer (http//www.pcpcc.net/conten
    ity-etc) Multiple resources from various
    sources aimed at helping the consumer/patient/fami
    ly better understand and become engaged in the
    PCMH model, including a video, brochures,
    checklists, guides, and white papers.
  • PCMH Pilot Compilation (http//www.pcpcc.net/conte
    nt/pcpcc-pilot-projects) A list of PCMH pilots
    underway and under development, along with their
    key features and contact information.

Can also link to these consumer resources via
the ACP website at http//www.acponline.org/runnin
Efforts to Test PCMH
  • Impetus for testing is need for reform/redesign
    ambulatory care practice, evidence of the value
    of primary care, initial evidence from PCMH
    tests, and support for PCMH concept
  • Much of initial evidence pertains to large
    practice settings, integrated delivery groups,
    e.g. Geisinger (Danville, PA) experience shows
    20 reduction in hospital admissions, 7 decrease
    in overall costs (Health Affairs, Sept/Oct 2008)
  • Particular need to test in small practices AND
    in rural areas

Efforts to Test PCMH (cont.)
  • Term medical home is used widely and can mean
    many things
  • Guidelines for PCMH Demonstration Projects -
    developed by ACP/AAFP/AAP/AOA to provide
    direction to projects in the planning phase in
    order to facilitate consistency with the Joint
    Principles they include recommendations about
  • Who should collaborate on the projects
  • How they should choose practices to participate
  • What kind of support should be provided to
    participating practices
  • How participating practices should be reimbursed
  • What each project should to do to analyze and
    distribute their results.

Detailed guidelines available at
Types of PCMH Test Projects
  • Multi-payer/multi-player commercial plans
  • Medicare Advantage
  • Medicaid transformation
  • Safety-Net Medical Home Iniative
  • Medicare FFS

Overview of PCMH Commercial Pilot Activity
  • 22 projects
  • 16 states
  • 12 are Multi-stakeholder
  • 10 are Insurer-based

Source PCPCC Pilot Report, as of Oct. 2008
Overview of PCMH Commercial Pilot Activity
  • Since October 2008
  • New commercial PCMH projects under development in
    at least 4 more states
  • Maryland
  • Indiana
  • Alabama
  • California

Examples of Multi-Stakeholder Efforts to Test
PCMH Pennsylvania
  • Pennsylvania Chronic Care Commission Rollouts
  • An integration of the Chronic Care Model and the
    Patient-Centered Medical Home concept
  • Six rollouts across the state southeast, south
    central, southwest, northeast, northwest, north
    central project underway and to run for three
  • Involves multiple health plans in each area,
    including Medicaid and Medicare Advantage
  • Includes over 100 internal medicine, family
    medicine, pediatric, and NP-led practices (in
    urban, suburban, and rural areas)
  • Utilizing NCQA recognition program
  • 3-component payment structure (1) prospective
    infrastructure development payments, (2) enhanced
    FFS/capitation via lump sum payments associated
    with level of achievement on NCQA PPC-PCMH, (3)
    P4P using a consistent set of core measures by
  • Practice support provided by Improving
    Performance In Practice, a Robert Wood Johnson
    Foundation funded quality improvement program
    that is located in several states

Examples of Multi-Stakeholder Efforts to Test
PCMH Louisiana
Source Karen DeSalvo, presentation to the PCPCC
on June 16, 2009 (given by Clayton Williams).
Initiatives to Advance Medical Homes in Medicaid/
Identified to have a medical home initiative
Source National Academy for State Health Policy
State Scan, November 2008
State Medicaid/SCHIP Innovation (cont.)
  • Over 30 states trying to improve medical home
    availability in Medicaid/SCHIP programs - via
    legislative authority or mandates, Medicaid
    Transformation Grants, dedicated state resources
  • Private Sector Multi-Stakeholder PCMH Pilots
    Involving Medicaid
  • Colorado
  • Louisiana
  • Maine
  • New Hampshire
  • Rhode Island
  • Vermont

Source National Academy of State Health
Policy (NASHP) http//www.nashp.org/files/medic
alhomesfinal.pdf discusses 10 states in depth
State Policy PCMH Implementation
  • Introduced Legislation in 2009
  • California
  • New Jersey
  • Hawaii
  • Maryland
  • Nebraska
  • West Virginia
  • Texas
  • Washington
  • Wyoming
  • Introduced Legislation in 2008
  • Iowa
  • Kansas
  • Massachusetts
  • New Hampshire
  • New York
  • Oklahoma
  • Minnesota
  • Washington
  • Maryland
  • Maine
  • Vermont
  • Utah
  • Enacted Legislation in 2007 and 2008
  • Colorado
  • Louisiana
  • Minnesota
  • Iowa
  • Washington
  • Oklahoma
  • Maine
  • New York

Safety-Net Medical Home Initiative
  • Launched by The Commonwealth Fund, Qualis Health
    and the MacColl Institute for Healthcare
  • Project duration April 2009 April 2013
  • Project goal to develop a replicable and
    sustainable implementation model for medical home
  • Five Regional Coordinating Centers (RCCs) have
    been selected
  • Colorado Community Health Network
  • Executive Office of Health and Human Services 
    Massachusetts League of Community Health Centers
  • Idaho Primary Care Association
  • Oregon Primary Care Association  CareOregon
  • Pittsburgh Regional Health Initiative

For more information http//www.qhmedicalhome.or
Safety-Net Medical Home Initiative (cont.)
  • Each RCC has partnered with 12-15 safety net
    clinics in their state.
  • These collaboratives will receive technical
    assistance on practice re-design topics such as
    enhanced access, care coordination and patient
  • They will also receive funding to support a
    Medical Home Facilitator (who will lead
    clinic-based quality improvement projects) and
    other activities.

For more information http//www.qhmedicalhome.or
Medicare Medical Home Demo
  • Authorized under Section 204 of the Tax Relief
    and Health Care Act of 2006
  • 3-year demonstration
  • RUC made recommendations for care management fees

Medicare Medical Home Demo (cont.)
  • Physician Eligibility
  • Family practice, IM, geriatrics, general
    practice, and some specialty/subspecialty
    practices (CHCs are specifically included)
  • Patient Eligibility
  • Medicare Part A B, FFS Medicare as primary
  • Qualifying chronic disease
  • Site Selection
  • 8 sites, 50 practices per site 400 practices
    total (approx. 2000 physicians)
  • Geographic distribution sufficiently large
    Medicare FFS population
  • No other CMS demonstration projects in the area
  • Preference given to Medicare high cost areas
    and sites with private payer medical home

Medicare Medical Home Demo (cont.)
  • Monthly Medical Home Fees
  • Tier 1 and Tier 2 using revised version of NCQA
  • Adjusted using Hierarchal Condition Code (HCC) to
    reflect severity and burden
  • Estimate that 25 of beneficiaries with HCC lt1.6
    and Medicare costs at least 60 higher than
  • First 2 of savings not shared
  • 80 of savings above 2 (minus fees) shared with

More Information on PCMH Demonstration Projects
See the ACP website http//www.acponline.org/runn
Efforts Underway/the Future
  • Multi-payer demonstration projects 2008 2010
    and beyond (discussed earlier)
  • Medicare Medical Home Demo 2010 (discussed
  • Role of subspecialists/specialists
  • Support for practices
  • Facilitating coordination with other providers
    and caregivers to provide optimal care

Discussed further below
Efforts Underway/the Future
  • Identifying common/recommended evaluation
  • Consumer organization projects aimed at
    communicating PCMH to patients
  • Understanding/facilitating needed HIT
  • Educational reform for students/residents
  • PCMH as part of broader health care reform

Discussed further below
Specialty Care Connections
  • PCMH is NOT a gatekeeper system
  • Jointly develop/identify referral guidelines
  • Emphasis on transitions in care continuity
    (e.g., referral agreements, care transitions
  • Some subspecialists may want to qualify as PCMH
    most will likely prefer to be neighbors
  • ACP in discussions with several groups regarding
    the PCMH model and primary care/specialty care
    interface (sharing care)
  • ACP Council of Specialty Societies PCMH workgroup
    has developed FAQs on the relationship of the
    PCMH to specialty physicians

FAQs available at http//www.acponline.org/ru
Support for Practices
  • ACP Medical Home BuilderSM - on-line guidance for
    practices involved in incremental quality
    improvement changes - or significant
    transformation of their practices. Made up of 7
  • Patient-Centered Care Communication
  • Access Scheduling
  • Organization of Practice
  • Care Coordination Transitions in Care
  • Use of Technology
  • Population Management
  • Quality Improvement Performance Improvement
  • Additional information at http//www.acponline.o

Support for Practices (cont.)
  • MedHomeInfo - A resource for physicians and
    practices that want to participate in the
    Medicare Medical Home Demonstration.
  • Additional information at http//www.medhomeinfo.

PCMH Evaluations/Metrics
  • PCMH Evaluators Collaborative
  • Sponsored by The Commonwealth Fund
  • For researchers actively engaged in a PCMH
  • Objectives
  • Reach consensus about a standard set of data
    collection instruments
  • Reach consensus about a standard, core set of
    outcome measures
  • Share the Collaborative's consensus on
    instruments, metrics and/or methodological
    lessons with interested researchers around the
    country through public venues
  • Foster an ongoing and supportive exchange where
    evaluators share ideas that improve their
    evaluation designs

PCMH Evaluators Collaborative (cont.)
  • Measurement workgroups will propose standards
  • Patient experience
  • Physician/staff experience
  • Medical homeness
  • Clinical quality
  • Cost/efficiency
  • Process/implementation metrics
  • Proposed measure sets to be vetted with larger
    group of stakeholders
  • Additional information at LINK TO BE ADDED

Consumer and Patient Information
  • Introduction to the Patient-Centered Medical
    Home A multimedia program to explain the PCMH
    model to consumers. A collaboration between the
    Patient-Centered Primary Care Collaborative and
    Emmi Solutions.
  • Merck Patient Education Brochure and Checklist
    Developed for the PCPCC by Merck. in consultation
    with ACP and other organizations, to help health
    care professionals communicate with patients
    about the PCMH approach.
  • Primary Care A Miracle of Modern Medicine This
    brochure is a collaboration between Thomas
    Bodenheimer at the Center for Excellence in
    Primary Care at the Department of Family and
    Community Medicine at University of California,
    San Francisco and the John D. Stoeckle Center
    for Primary Care Innovation at Massachusetts
    General Hospital.

Links to these documents can be found
at http//www.acponline.org/running_practice/pcmh
/resources_tools/web.htm Additional consumer
materials can be found at http//www.pcpcc.net
Consumer and Patient Information (cont.)
  • National Partnership for Women and Families
    Medical Home Principles Developed by a broad
    coalition of more than 25 of the nation's leading
    consumer, labor, and health care advocacy groups
    to help health care providers, lawmakers,
    employers, and health plans consider consumer
    interests as they develop delivery system reforms
    such as the medical home.
  • Supporting Patient Engagement in the
    Patient-Centered Medical Home White paper on
    patient engagement in the PCMH produced by the
    Center for the Advancement of Health. It includes
    a Short Guide for Patients and a sample
    Patient-Clinician PACT.
  • Creating a Patient Guide for a Medical Home
    Physician Practice A resource by the Center for
    the Advancement of Health to assist medical home
    practices with creating a simple guide for their

Links to these documents can be found
at http//www.acponline.org/running_practice/pcmh
/resources_tools/web.htm Additional consumer
materials can be found at http//www.pcpcc.net
Understanding/Facilitating Needed Health
Information Technology
  • Meaningful Connections IT Resource Guide
  • White paper by the PCPCC.
  • Identifies the capabilities and functionalities
    of eHealth applications that experts consider
    crucial to support the PCMH.
  • Available at http//www.pcpcc.net/content/meaning

  • Now, there are some who question the scale of our
    ambitions, who suggest that our system cannot
    tolerate too many big plans. Their memories are
    short, for they have forgotten what this country
    has already done, what free men and women can
    achieve when imagination is joined to common
    purpose and necessity to courage.
  • What the cynics fail to understand is that the
    ground has shifted beneath them, that the stale
    political arguments that have consumed us for so
    long, no longer apply.
  • -President Barack Obama, January 20, 2009

Thank You!
Shari M. EricksonSenior Associate, Center for
Practice Improvement InnovationDivision of
Governmental Affairs Public PolicyWashington,
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