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

1
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

2

• 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
3

• 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
4
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
  services
• 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
  transparency
• United States is lagging internationally

5
Presentation Outline

• Overview of the patient-centered medical home
  model
• 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

6
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

7
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

8
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

9
Joint Principles-Recommended Supporting Payment
Structure

• 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
  components
• 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)
  payment
• Performance-based bonus payments based on
  evidence-based measures of care

10
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
  capabilities
• 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
  module
• Other entities can develop PCMH recognition
  process
• Recognized PCMHs would also be accountable for
  quality of care by reporting on evidence-based
  clinical and patient experience measuresprovides
  retrospective assurance

11
NCQA PPC-PCMH Recognition Module Major
Domains/Standards

• 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

12
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
13
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

14
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
  initiatives
• Additional technology solutions

15
More Features of a PCMH Practice

• Uses each team member to his/her highest
  capability
• 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

16
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

17
NCQA Recognition Activity

• 149 practices have received recognition across 17
  states
• 46 Level 1
• 4 Level 2
• 50 Level 3 (12 of 75 in practices of 1-2
  physicians)
• 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
18
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
  implementation

PCPCC on the web http//www.pcpcc.net
19
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

20
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
  (http//www.pcpcc.net/content/meaningful-connectio
  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
  t/engaging-consumer-family-patient-employee-commun
  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
g_practice/pcmh/resources_tools/web.htm.
21
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

22
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
  and
• What each project should to do to analyze and
  distribute their results.

Detailed guidelines available at
http//www.acponline.org/running_practice/pcmh/de
monstrations/guidedemo.pdf
23
Types of PCMH Test Projects

• Multi-payer/multi-player commercial plans
• Medicare Advantage
• Medicaid transformation
• Safety-Net Medical Home Iniative
• Medicare FFS

24
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
25
Overview of PCMH Commercial Pilot Activity
(cont.)

• Since October 2008
• New commercial PCMH projects under development in
  at least 4 more states
• Maryland
• Indiana
• Alabama
• California

26
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
  years
• Involves multiple health plans in each area,
  including Medicaid and Medicare Advantage
  business
• 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
  2010
• Practice support provided by Improving
  Performance In Practice, a Robert Wood Johnson
  Foundation funded quality improvement program
  that is located in several states

27
Examples of Multi-Stakeholder Efforts to Test
PCMH Louisiana
Source Karen DeSalvo, presentation to the PCPCC
on June 16, 2009 (given by Clayton Williams).
28
Initiatives to Advance Medical Homes in Medicaid/
SCHIP
Identified to have a medical home initiative
Source National Academy for State Health Policy
State Scan, November 2008
29
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
30
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

31
Safety-Net Medical Home Initiative

• Launched by The Commonwealth Fund, Qualis Health
  and the MacColl Institute for Healthcare
  Innovation
• Project duration April 2009 April 2013
• Project goal to develop a replicable and
  sustainable implementation model for medical home
  transformation
• 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
g/safety-net/index.cfm
32
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
  experience.
• 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
g/safety-net/index.cfm
33
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

34
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
  coverage
• 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
  demonstrations

35
Medicare Medical Home Demo (cont.)

• Monthly Medical Home Fees
• Tier 1 and Tier 2 using revised version of NCQA
  PPC-PCMH
• 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
  average
• First 2 of savings not shared
• 80 of savings above 2 (minus fees) shared with
  practices

36
More Information on PCMH Demonstration Projects
See the ACP website http//www.acponline.org/runn
ing_practice/pcmh/demonstrations/index.html
37
Efforts Underway/the Future

• Multi-payer demonstration projects 2008 2010
  and beyond (discussed earlier)
• Medicare Medical Home Demo 2010 (discussed
  earlier)
• Role of subspecialists/specialists
• Support for practices
• Facilitating coordination with other providers
  and caregivers to provide optimal care

Discussed further below
38
Efforts Underway/the Future

• Identifying common/recommended evaluation
  metrics
• 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
39
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
  programs)
• 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
nning_practice/pcmh/understanding/specialty_physic
ians.htm
40
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
  modules
• 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
  rg/running_practice/pcmh/help.htm

41
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.
  org/

42
PCMH Evaluations/Metrics

• PCMH Evaluators Collaborative
• Sponsored by The Commonwealth Fund
• For researchers actively engaged in a PCMH
  evaluation
• 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

43
PCMH Evaluators Collaborative (cont.)

• Measurement workgroups will propose standards
  for
• 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

44
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
45
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
  patients.

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
46
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
  ful-connections-it-resource-guide

47

• 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

48
Thank You!
Shari M. EricksonSenior Associate, Center for
Practice Improvement InnovationDivision of
Governmental Affairs Public PolicyWashington,
DCserickson_at_acponline.org202-261-4551