CMS announces new initiative in Advanced Primary Care

Advanced Primary Care Initiatives

The Centers for Medicare & Medicaid Services (CMS) is seeking input on initiatives to test innovations in advanced primary care, particularly mechanisms to encourage more comprehensiveness in primary care delivery; to improve the care of complex patients; to facilitate robust connections to the medical neighborhood and community-based services; and to move reimbursement from encounter-based towards value-driven, population-based care.

Background

Advanced primary care is based on principles of the Patient Centered Medical Home and builds on the care delivery models employed in other CMS model tests, including the Comprehensive Primary Care Initiative. Next generation model(s) for advanced primary care would seek to improve further the delivery of patient-centered care and population health. General topics of interest include:

• increased comprehensiveness of, and patient continuity with, primary care (i.e., care provided with greater depth and breadth and through longitudinal relationships between patients and primary care providers),
• care of patients with complex needs, 
• closer connections between primary care and other clinical care (“the medical neighborhood”) and community-based services, 
• moving from encounter-based payment or encounter-based payment with care management fees towards population-based payments (PBPs) to support the infrastructure needed for advanced primary care, create incentives for innovation in care delivery, and promote accountability for costs and quality of care, including consideration of appropriate mechanisms to assign beneficiaries to unique practices, 
• mechanisms to support small primary care practices in the transformation to advanced primary care,
• advanced primary care within accountable care organizations (ACOs),
• multi-payer participation,
• performance measurement that is meaningful to beneficiaries and clinicians,
• matching documentation requirements to the goals of advanced primary care while protecting MS program integrity, and
• use of health information technology (HIT), including electronic health records, data analytics, and population health tools, to support advanced primary care.

Request For Information

CMS seeks broad input from consumers and consumer organizations, health care providers, associations, purchasers and health plans, Medicaid agencies and other state offices, quality review organizations, social service providers, HIT vendors, and other stakeholders. Submissions must be supplied using the Request for Information (RFI) (PDF). To be assured consideration, comments must be received on or before 11:59pm EDT, March 16, 2015. For questions regarding RFI submission please contact APC@cms.hhs.gov.

Additional Information

• Request for Information (RFI) (PDF)

What are your patients doing while they wait?

Remember that time as a child in class when the teacher finally asked a question that you knew the answer to. Your hand shot up and it didn’t matter how hard you tried, you just couldn’t stay seated. 

That single moment was an act of boldness - ignited by knowledge.

Engage – Educate – Empower

That is the cycle of learning that changes behaviors, that builds self-efficacy and ultimately inspires active participation.

mHealth Games Interactive Clipboards will empower and inspire just as your favorite grade school teacher once did. 

Click the image above to explore the interactive clipboard from mHealth Games

PCMH: Best Practices in Communication

Keeping patients healthy and out of the hospital requires team work. These two short simulations illustrate best practices in communication for medical practices and demonstrate the importance of proactive engagement.

Prescription Refills - Click the picture below to launch.
It is very dangerous for patients to skip medication. This 3 minute interaction illustrates how the front line staff can work with clinicians, patients, and caregivers to ensure timely medication refills.

Best Practices in Communication - Click the picture below to launch. 
This simulation illustrates how the front line staff can influence overall health outcomes.

Five essentials for building the patient-centered medical home

Author Name Jennifer Bresnick   |   Date July 28, 2014 

The patient-centered medical home (PCMH) is becoming one of the most coveted recognitions for healthcare providers in urgent need of better ways to manage population health, close care gaps, and reduce wasteful spending.  As evidence of the model’s effectiveness mounts in conjunction with the shift towards accountable care reimbursement models, what are some of the most critical building blocks for the medical home, and how can providers begin their journey towards developing a system of data-driven, patient-centered care?

Roadmap to success

Providers can operate under the PCMH model without being officially recognized as such, but organizations such as NCQA and the American Academy of Family Physicians (AAFP) offer roadmaps and planning tools to guide providers towards the principles of PCMH operations.  Providers may also wish to bring in consultants that will examine their operations, workflows, and clinical health IT infrastructure maturity while making suggestions about the next steps towards developing strong relationships with patients and partner organizations.

Providers should be aware, however, that moving to the PCMH model does require significant investment in both time and resources, warns Michael Meucci, Director of Transformation and Improvement at Arcadia Healthcare Solutions.  “The medical home is a really resource-intensive model,” he says.  “You go from having a physician who has a one-on-one relationship to a patient to a team-based model where a team has a relationship with the patient.”

Strong leadership and staff commitment

The most important key for success is a strong commitment to that overall transformation, a clear leadership structure that engages all levels of staff, and effective communication within the organization as changes are being made.  “When we look at some of our most successful transformations, we see strong leadership buy-in,” Meucci says.  “[One client] built a steering committee that was made up of representation from the executive leadership team, practice leadership, medical leadership, and technology leadership.  It was really every functional area of that organization that was represented on this team.”

“One of the comments that we heard from [our client organization’s staff] was that they were excited to be asked questions about their patients and their care, because historically they had just been given edicts in terms of what they needed to do, and then they were expected to go do it without question,” adds LuAnn Kimker, RN MSN, CPHIMS, PCMH CCE, Director of Clinical Quality Improvement at Arcadia Healthcare Solutions.

In health systems with multiple locations, the PCMH model can help to standardize workflow and clinical tasks throughout the organization, leading to a reduction in potentially harmful variations and an increase in overall quality, communication, and adherence to the organization’s goals.

“The PCMH model really standardizes things across health centers,” said Carol Mensch, MSN RN-BC, Performance Improvement Coordinator at ChesPenn Health Services. “As a community health center, it really changes things to emphasize the patient-centered aspect of care.  If we hadn’t gone the PCMH direction, the Healthy People goals we follow might have pushed us towards those population health features, as well.  But having [the PCMH structure] helps us focus and channel some of our areas of need.”

An underlying technical infrastructure

While EHR adopters can succeed with many of the PCMH principles without an additional outlay in technological infrastructure, clinical analytics and population health management tools can expand a provider’s capabilities to conduct risk assessments, stratify patients, preempt non-adherence, and prevent 30-day readmissions that often come with a hefty financial penalty.  Many of the most technologically savvy organizations in the nation have invested heavily in predictive analytics and data warehousing.

“We are using real-time algorithms within and outside of the EHR to look at risk, and predict and inform clinical and operational pathways,” says Steve Hess, CIO, University of Colorado Health, one of this year’s “Most Wired” hospitals. “While still early, we are starting to see patterns related to how our patients are interacting with our system and the reimbursement impact of those changes. It is important that our systems are set up to provide the complete patient picture and to ensure that the patient is getting the appropriate care in the appropriate setting at the right time.”

Effective patient engagement tools

In addition to in-house analytics, providers must invest in patient engagement if the PCMH is to be successful.  Helping patients manage their chronic diseases, show up for screenings and other primary care services, and access their health information to improve literacy and encourage healthy choices are key features of the PCMH, and health IT tools are available to help.  The patient portal is a pillar of Stage 2 meaningful use, and is a wildly popular feature with patients.

“We recently started a system-wide patient engagement education that includes media, TV, and print, encouraging patients to talk to their providers about using our portal,” explains Catholic Health Partners CMIO Stephen Beck, MD, FACP, FHIMSS. “The intent is to educate patients and continue to educate our providers as we realize there is some economy in the use of our patient portal.”

“Collaboration across the community is going to be a very positive outcome from this work,” he added. “Some communities are well connected right now with HIEs and other interaction at the community level, but most are still very competitive. By nature of making it easier to share information about patient care and improving continuity, I hope the patient will be the winner relative to meaningful use and HIE integration.”

Community stakeholder buy-in

Those community connections provide the foundation for a truly effective PCMH.  Primary care providers can no longer work in isolation, sending patients out to specialists but rarely receiving feedback on the results.  By working together as a “medical neighborhood” instead of individual organizations spending money and man-hours faxing documents back and forth, both providers and patients can reap significant benefits.  Patients may not always understand their responsibilities when it comes to coordinating their care, and hospitals waste millions every year on inefficient communications, lengthy transitions, and waiting for information from colleagues.

“It is important for all health care professionals involved in patient care to have a solid understanding of the role of the patient and family in articulating needs and developing a care plan,” says AAFP. “PCMH integration enables warm handoffs at the moment the patient or family is ready and, thus reduces stigma, improves adherence and augments access to support groups, parenting programs and other medical neighborhood services.”

http://healthitanalytics.com/2014/07/28/five-essentials-for-building-the-patient-centered-medical-home/

The next-generation set of standards for patient-centered medical homes, called PCMH 2014.

The National Committee for Quality Assurance has released a next-generation set of standards for patient-centered medical homes, called PCMH 2014.

The accreditation organization uses the standards to assess primary care practices seeking NCQA PCMH Recognition. About 7,000 practice sites with 35,500 clinicians have received recognition and that accounts for more than 10 percent of the nation’s practices, according to NCQA.

The new standards cover six primary areas: patient-centered access, team-based care, population health management, care management and support, care coordination and care transitions, and performance measurement and quality improvement.

Further, there are six must-pass elements necessary for recognition: patient-centered appointment access, components of the practice team, using data for population management, care planning and self-care support, referral tracking and follow-up, and implementing continuous quality improvement.

“To earn NCQA recognition, practices must meet rigorous standards for addressing patient needs; for example, offering access after office hours and online so patients can get care and advice where and when they need it,” according to the organization. “PCMHs get to know patients in long-term partnerships, rather than through hurried, sporadic visits. They make treatment decisions with their patients, based on patient preference. They help patients become engaged in their own healthy behaviors and healthcare.”

NCQA also continues to emphasize the importance of meaningful use of health information technology and health information exchange to support coordinated and patient-centered care, across provider sites.

According to NCQA, changes in the new standards include:

* Integrating behavioral health into a practice: Practices are expected to collaborate with behavioral health providers and communicate the benefits of such treatment to patients.

* Focusing care management on high-need populations:  Practices are expected to address socioeconomic drivers of health and poorly controlled or complex conditions.

* Enhanced emphasis on team-based care: This includes a higher emphasis on collaboration with patients and establishing team-based care as a “must-pass” criterion.

* Implementing the Triple Aim of care: Practices must demonstrate improving use of the three domains of Triple Aim--patient experience, cost and clinical quality.

* Sustained transformation: Practices must show they comply with NCQA standards over long periods.

The new patient-centered medical home standards are available here.

http://www.healthdatamanagement.com/news/NCQA-Sets-New-Higher-Standards-for-Medical-Homes-47568-1.html

PCMH Model is Alive and Well Despite One Negative Study

March 12, 2014 03:12 pm "Voices" Staff – The Patient-Centered Primary Care Collaborative (PCPCC) released a report in January that reviewed 20 patient-centered medical home (PCMH) studies released in the previous 17 months.

The majority of those studies found overall cost reductions and decreases in ER visits, and 40 percent reported fewer hospital admissions. Smaller percentages of the studies reported improvements in other vital areas, including improved population health or increased use of preventive services (30 percent), improvements in access to care (25 percent), patient satisfaction (20 percent), and hospital readmissions (15 percent).

Although that report reinforced the concept of the PCMH as the future model of primary care and provided a five-year summary of evidence supporting the model(www.pcpcc.org), it didn't generate much media attention. Good news rarely does.

Fast forward one month. The Journal of the American Medical Association (JAMA) released one PCMH study(jama.jamanetwork.com) in late February that found "limited improvements in quality" and no association with reductions in use of hospital, ER or ambulatory care services or total costs. Based on that one study, reports in some daily newspapers and on medical news websites declared the PCMH a failure. If the PCMH could be likened to a horse, it would be fair to say that some particularly critical bloggers were ready to take it out back and shoot it.

Well, put your shovels away. There will be no burial today.

The PCMH is a work in progress. The AAFP has been developing the model for 10 years, a result of the original Future of Family Medicine project. Despite the findings of this one study, we still think the PCMH is a vital part of our specialty's future. The Academy and others will continue to study and refine it.

Mark Friedberg, M.D., the corresponding author of the JAMA article, said in an interview with AAFP News that physicians should not "attach too much importance to any study" and that more research on the PCMH is needed.

It's worth noting that the Pennsylvania Chronic Care Initiative, the program studied in the JAMA article, launched in 2008 under PCMH standards that were updated by the National Committee for Quality Assurance (NCQA) three years later. NCQA plans to update its standards again(www.ncqa.org) this month. Again, it's a work in progress. We know more now than we did in 2008 about what works, what's required and how to implement it.

The JAMA study has other limitations, too.

The Pennsylvania practices involved in the study were given incentives to earn PCMH recognition but no incentives to reduce costs. The project also failed to target chronically ill patients. With no incentive to control costs and no priority to help improve the health of the system's biggest users of care, should it be a surprise that costs did not decline?

Becoming recognized as a PCMH does not magically improve care and reduce costs. There is more to it than marking off the boxes on a checklist. For example, improving access to care is an element of the PCMH, but practices in the study didn't offer evening hours or weekend care because that step isn't required to earn PCMH recognition. But that kind of patient-centered effort can lead to reduced health care costs and less use of ERs and hospitalization.

Furthermore, only half the NCQA-recognized practices in the study achieved Level 3. According to NCQA, 75 percent of recognized practices in pilot projects typically achieve Level 3. "A higher (and more typical) concentration of high-capability medical homes would probably have produced better outcomes," NCQA said in its response to the study(www.ncqa.org).

The PCPCC also responded(www.pcpcc.org), saying the study failed to measure other key elements of the PCMH, including patient engagement and satisfaction, team-based care, and behavioral health integration.

The Commonwealth Fund, which helped fund the Pennsylvania study, also defended the PCMH(www.commonwealthfund.org), making some of the same points we have here: that we better understand how to implement the model than we did in 2008, and patients with complex conditions should be targeted to improve outcomes and reduce utilization and costs. It also points out that the three-year study may not have been long enough to see the long-term benefits of the model.

Since the JAMA study was initiated in 2008, six other regions of Pennsylvania have started their own pilots. Based on lessons learned from the first study, these subsequent projects have been updated accordingly. It will be interesting to see the findings when these more recent projects are completed.

The bottom line is that one study that questions the value of the PCMH is no more valuable than one study that supports it. No one study should drastically alter the way we practice medicine. It is the totality of evidence that matters, and right now, we have a mountain of evidence that shows that in the majority of studies, the PCMH has been shown to decrease costs and improve outcomes.

One study can get our attention, which this one surely did, and make us scrutinize what we are doing. The JAMA article could help us learn how to better implement and study this evolving model, but it should not lead us to abandon it.

http://www.aafp.org/news/opinion/20140312pcmhjamaedl.html

Almost 80 Percent Of Practices Deemed 'Better-Performers' Conduct Patient-Satisfaction Surveys

News | November 13, 2013

 

Almost 80 percent of medical practices deemed “better-performers” by the MGMA Performance and Practices of Successful Medical Groups: 2013  Report Based on 2012 Data indicated they used patient-satisfaction surveys. Compared with other practices, better-performers were more likely to assess patient satisfaction in their practice and did so more frequently.

Practices conducted satisfaction surveys to gauge, among other things, their patients' overall experience, professionalism of the staff, availability of appointments, and quality of care. More than half of better-performing medical practices indicated they used patient-satisfaction surveys to evaluate and improve practice operations and educate staff and physicians about behavior.

“Successful groups actively and regularly solicit feedback from their patients,” said Kenneth T. Hertz, FACMPE, Principal, MGMA Health Care Consulting Group. “Patient satisfaction surveys give practices an immense amount of detail on their patients' experience, and that feedback is particularly useful as medical groups seek to improve and elevate the care they provide.”

Almost 10 percent of better-performing practices cited using patient-satisfaction survey results as “part of physician compensation formula.” In June, MGMA released the Physician Compensation Survey Report and results indicated that quality and patient-satisfaction measures appeared to be a small yet emerging component of total compensation for physicians.

MGMA member Martha Kelley, administrator, Virginia Anesthesia & Perioperative Care Specialists, Newport News, Va., developed a performance-based risk program with a hospital system and tied patient-satisfaction measures to their physicians' compensation. “We started surveying patients for our own internal quality program several years ago, and now we’re required to meet established criteria with one of our hospitals,” Kelley said. “We share results from our patient-satisfaction survey with the hospital, and this metric now ultimately impacts physician compensation. We appreciate the feedback we receive and are continuing to explore ways in which to serve patients better.”

The MGMA Performance and Practices of Successful Medical Groups: 2013  Report Based on 2012 Data survey report is compiled using data from the MGMA 2013 Cost Survey pertaining to: profitability and cost management; productivity, capacity and staffing; accounts receivable (A/R) and collections; and patient satisfaction. The report features success stories from organizations and how they tackled issues to achieve their status as better-performers.

Read more: http://www.healthcaretechnologyonline.com/doc/almost-percent-better-performers-conduct-patient-satisfaction-0001

Report Highlights Role of Health IT in Managing Patient Population Health

November 06, 2013 01:36 pm Sheri Porter – Family physicians in the throes of creating patient-centered medical home (PCMH) practices, learning about medical neighborhoods, and gaining full functionality of their electronic health records (EHRs) may appreciate a new report that illustrates how those three activities work together to benefit patients.

The report, "Managing Populations, Maximizing Technology: Population Health Management in the Medical Neighborhood,(www.pcpcc.org)" was released by the Patient-Centered Primary Care Collaborative (PCPCC) at its annual meeting in October.

Report co-author Michelle Shaljian, M.P.A., the PCPCC's director of public affairs, sums up the report's value to busy family physicians this way: "We're seeing the evolution of the patient-centered medical home from a practice-level philosophy to a community-level philosophy, so we really wanted to give physicians, clinicians and community stakeholders a perspective on how this could be done at a much broader level."


Key Points

Report authors note that a population health approach -- where stakeholders calculate the health outcomes of a group of individuals -- requires collaboration among patients, physicians, insurance companies, the government, the private sector and local communities.

"While our current system is designed to respond to the acute needs of individual patients, it must transition to one that anticipates and shapes patterns of care for populations and addresses the environmental and social determinants of health," says the report.

According to the report, the PCMH sits at the center of the model and is surrounded by the larger and more inclusive medical neighborhood. It is the neighborhood that connects physician practices to hospitals, home health agencies, mental health agencies, and community organizations that encourage healthy lifestyles and safe environments. But health information technology (IT) is the foundation of it all.

"We believe a critical tool in this effort will be the widespread adoption of health information technology," says the report. Health IT offers a structure to help primary care practices within and throughout the medical neighborhood provide better access to care, communicate more effectively and work together as teams.

"Implemented effectively, it also has tremendous potential to identify health trends in local communities, exchange information across organizations, coordinate care as patients transition between providers, and enables secure communications between providers and their patients and families."
The report recommends 10 specific health IT tools and strategies that can help achieve population health management in the medical neighborhood. The essentials and their functions are

• electronic health records to perform documentation tasks, populate patient registries and create structured data;
• patient registries to act as the central database for patient monitoring and care management;
• health information exchange to enable coordination of care;
• risk stratification to classify patients by their health status and health risk;
• automated outreach to generate messaging to patients who need preventive or chronic disease care;
• referral tracking to ensure receipt of test results from outside consultations;
• patient portals to engage patients in health care self-management;
• telemedicine to engage patients between face-to-face visits and to help reduce those in-person encounters;
• remote patient monitoring to allow for quick physician intervention and enable patient control of chronic conditions; and
• advanced population analytics that allow evaluation of patient population segments and assessment of organizational performance.

Working Models

The report includes three case studies in population management. "I want to emphasize the diversity and range that we have included in the case studies," says Shaljian. The case studies focus on a group of pediatric practices in Winston-Salem, N.C.; a community health center in New York City; and a multispecialty group practice in Richmond, Va.

"These are very different practices, and they all are dealing with very different populations and different needs of their communities," says Shaljian. "But they all seem to make it work with this ideology in place."

For example, the case study focusing on Bon Secours Virginia Medical Group in Richmond examines how the organization -- with 140 locations and 25,000 patients -- manages patient risk in an accountable care organization model.

Bon Secours implemented a care team model as part of an advanced medical home pilot project in June 2010. The practice took a number of steps, including

embedding care managers in the form of nurse navigators into the primary care team,
implementing health IT that empowered the care team to efficiently manage the health of patient populations,
building a registry to identify high-risk and high-use patients,
implementing an automatic outreach program to prevent 30-day hospital readmissions, and
engaging patients via personal health records and email communication with caregivers.
"For the first few years of the project, Bon Secours shouldered the expense," says the report. "The organization is now poised to reap the rewards of its investment."

In the first six months of its value-based contract with CIGNA, the group practice achieved a 27 percent reduction in readmissions and is $1.8 million below its projected spending. The group has hit many care-quality metrics and soon will qualify for "gain sharing (with CIGNA), a development that will bring a projected annual savings of $4 million," says the report.

Looking Ahead

According to the report's authors, the United States is long overdue for payment reform that encourages a population-based approach to better health.

"PHM (population health management) strategies will not be possible until new financial incentives in health care evolve and become prevalent," say the authors. The current fee-for-service payment system "discourages providers from caring for patients outside of face-to-face encounters or proactively seeking out patients with gaps in their preventive or chronic disease care."

Improvements in health IT, including "out-of-the-box" features to simplify tasks, also are in order, say the authors, as is enhanced workforce education and training to educate physicians and other clinical staff members on how to effectively use EHRs and PHM tools.

"It will also be critical to incorporate the PHM and meaningful use model into medical school curricula and accreditation exams," say the authors.

Lastly, patients should be encouraged to manage their own health or disease status. "Accounting for population health requires a lot of things, but most importantly, it's the relationship between the patients and their providers, the providers and their colleagues, and those practices and the rest of the community," says Shaljian.

"It's an all-in kind of approach to population health, and it's not just health IT; it's about what people are doing with that health IT to make all of these improvements and innovations."

Shaljian says family physicians have always been extremely aware of the needs of patients and their families, so incorporating a population health philosophy would build a bridge "between the patients they've been taking care of for so long and the rest of the community."

Physicians can begin to address questions about which of their patients are most at risk and how to proactively reach out to them, says Shaljian. And, practices can identify where costs are coming from, which, in turn, will allow them to manage the business end of the practice more effectively.

"This is about bringing all the pieces together," says Shaljian. "It's a very forward-looking approach to family medicine."

Read more:  http://www.aafp.org/news-now/practice-professional-issues/20131106popmodel.html

Private Practice: The End of an Era or a Value Added Proposition?

-Kameron Gifford, CPC  10/11/13

The practice of medicine in America is changing rapidly under new regulations, greater enforcement and tightening reimbursement policies. We are seeing more and more physicians opting to sell their practices rather than the time honored tradition of “modify and adapt”.

This month marks a significant point in our journey down the road of “Healthcare Reform” for the entire industry, but to me, it means more than the opening of healthcare exchanges and the final countdown to ICD-10; it signifies the potential end of an era. 

Just as any other small business owner, my father has worked countless hours building his business from the ground up. Over the last 35 years, he has kept his patients healthy, managed employees, handled payroll and navigated numerous changes in insurance and healthcare reform. He has supervised residents, moonlighted in the Emergency Room, held medical directorships and worked hand in hand with managed care companies to improve their outcomes. 

On October 2^nd, at 70 years old, he sold his private practice to a “corporate medical group.” This sell was bitter sweet for me as I have come to know and care for each and every one of our patients.  As a child, I spent many summer days reading medical text books in his office and accompanying him on hospital rounds. As an adult, I was honored to work side by side with him as his office manager.

Today, I ponder the future experiences of my patients and the overall effect on outcomes. Who will “lead” their plight for wellness now? What does the commercialization of primary care mean for consumers? What is the ultimate number of dollars saved versus the experience of the care delivered? And how will corporate medicine ultimately affect future access?

Policies and procedures are a necessary evil in terms of practice management. For example, we did not accept walk-ins, but I never turned a patient away from my window. Would you shut the door on a friend in need? Of course not, even when it is inconvenient . When Mr. Hernandez’s grandson was visiting from New York, and was stung by a jelly fish, we worked him in, even though he was 17, and we did not see anyone under 18. This flexibility on the front line increases patient satisfaction and improves the overall experience of care. 

When you called the office, there was a 1 in 3 chance that I (the office manager) would answer the phone. Why, because during clinic, I sat up front and checked out every patient. Because this is the last step in the process, and ultimately your last opportunity to ensure that your “customer” leaves with a smile, or at least a clear understanding of what to do next. My “instructions” came in many different vehicles, but the over arching theme was “please call with questions, I am here to help and I care”.

Same day appointments were always available and “no show” patients didn’t exist. When employers changed plans and Mr. Jones forgot his insurance card, we still checked his blood pressure, and when Mrs. Allen accidentally enrolled in a plan we were not participating with, we continued her treating her all year without a charge. Why? Because after 15 years of care it was the right thing to do. Mrs. Allen only came in twice that year, but 5 years later she is still with us. When new members were added to our managed care rosters, we reached out to them, instead of waiting for them to contact us. All this was standard procedure, years before the ACA or quality incentives. 

My father ran his practice with strict protocols. He took the history of all new patients, personally. Our collection of new patient forms did not include the standard lists of boxes to check. His “standard” set of questions had been refined again and again through out the years to ensure a “yes” or “no” answer would be difficult. Instead of “do you drink?” it might be “what did you drink with dinner last night?” or "how much do you drink?" Antibiotics were never given out over the phone, and sinus infections were confirmed by a sinus x-ray before writing the prescription. All appointments for tests and specialists were made by us, without exception. Why? Because this ensured we always received the report, and would be able to remind them when and where they were to go. Diabetics and pre-diabetics were seen every 3 months fasting, and we tracked and monitored all LDL’s internally on a quarterly basis. Every  patient had a comprehensive physical exam, even before Medicare Wellness Exams were reimbursed. And when you came to our office for our physical, you met with doctor in his office, after getting dressed to discus the results. All of this, long before primary care came into the spotlight, and quality was ever mentioned in terms of payment.
So, what value has this acquisition ultimately added to the experience of care for my patients? Will the shiny new furniture and upgraded computers really have an impact on their health? And what about the "standards" of corporate medicine? Will the new spirometery machine really improve the overall health of the population, or will it's purpose be closer tied to revenue?

I can’t help but wonder what will be lost in translation from private practice to corporate medicine? If Mrs. Jackson calls without her hearing aids in, will a live person be there to assist her? Or will she be forced to fumble through an automated phone system? And if she gets a voicemail instead of a person, how will that ultimately influence her decision to seek or not to seek care?

Now consider for a moment the potential financial impact of 1 coronary event, or the prevention of 1 coronary event.  That phone call might have been our single opportunity to reduce the probability of a negative outcome.  

I am willing to bet that the magical point of sustainability in our healthcare system lies within both our past experiences and future capabilities. Perhaps the answer we are all searching so desperately to find is not black and white, but instead a mix of "old" and "new." As an industry, I believe that we need to embrace the collective experiences of those who have been on the front lines, and work together to create innovative solutions instead of closing the door on an era and such a wealth of intelligence.  There is no one that knows what your members need or want more than the person that answers the phone at your PCP’s office. I believe the most innovative solutions are yet to come.  What could this collective intelligence add to your current value proposition?

Patient-centered medical home philosophy boosts patient, physician satisfaction

UCLA-USC intervention could encourage more new docs to enter primary care

By Enrique Rivero October 08, 2013

The common refrain about health care is that it's a broken system. A new joint program between UCLA and USC demonstrates a way to mend the system with a new patient-centered program that is getting rave reviews from patients and from the residents and nurses who provide their care.

 

The program, Galaxy Health, debuted at Los Angeles County+USC Medical Center in 2012 with the goal of substantially improving an on-site clinic for residents and demonstrating to county officials that intuitive and inexpensive interventions can dramatically improve patient care and physician and staff morale.

 

A new UCLA–USC study published online in the JAMA Internal Medicine, a peer-reviewed journal of the American Medical Association, outlines how the Galaxy model works in a public setting, with a favorable effect on both patients and medical residents.

 

"We all know that fewer and fewer young physicians are choosing careers in primary care because of the difficult work schedules, lack of support and lower salaries," said lead study author Dr. Michael Hochman, who conducted the research as a Robert Wood Johnson Clinical Scholar in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA. "What we did here was to move in the direction of a team-based approach, and it resulted in improved satisfaction for physicians-in-training with their primary care experiences."

 

Dr. David Goldstein, an associate professor of clinical medicine at USC's Keck School of Medicine and chief of the division of geriatric, hospital, palliative and general internal medicine at LAC+USC Medical Center, was the study's senior author. He conceived the Galaxy Health program.

 

"My hope was that Galaxy would reveal that a minimal investment and reorientation in delivery focused on the patient and enhanced access to care could improve the satisfaction of patients, staff and physicians, even in an underfunded public environment," he said. "I think it worked out well. It's not rocket science."

 

The Galaxy model established round-the-clock, seven-day-a-week access to physicians, made urgent clinic appointments available within hours and coordinated care in the ambulatory environment. It was based in part on increasing interest in a concept known as the patient-centered "medical home," which provides a team-based, coordinated approach to care that aims to make the primary care team central to the patient’s health needs. While the concept may not sound that different from the traditional vision of high-quality primary care, Galaxy's innovation is making this vision a reality in a complex, disconnected health care system.

 

"Galaxy Health has proven its value and effectiveness, as measured by patient satisfaction, access to care and provider satisfaction, in an incredibly challenging clinical environment," said Christina Ghaly, interim CEO of LAC+USC Medical Center. "Its remarkable success is to the benefit of our patients at LAC+USC Medical Center and can be a model for other safety-net, resident-run clinics struggling with implementing patient-centered medical homes."

 

The project was funded primarily by a three-year, $750,000 grant from UniHealth Foundation.

 

The study findings also support further investment in primary care, particularly in teaching settings, where the next generation of primary care leaders will be developed, said Hochman, now medical director for innovation at AltaMed Health Services, a large federally qualified health center in Southern California. There is currently a shortage of primary care physicians, and the situation is expected to become more acute as baby boomers continue to reach retirement age.

 

The researchers conducted their study at three primary-care internal medicine clinics at LAC+USC, an urban academic medical center serving a safety-net population. They focused on expanded access to care, enhanced care coordination and team-based care. Galaxy Health included the creation of a call center staffed by two care coordinators, telephone renewal of prescriptions and the availability of up to five urgent care appointments each day.

 

Input from patients and staff during prior focus groups was incorporated into the study. The researchers surveyed patients and residents before the intervention and again one year later. They also analyzed emergency room and hospital visit rates.

 

Though the clinics did not satisfy all the elements needed to qualify as a patient-centered medical home, overall their score jumped from a previous 35 to 53 out of 100 possible points. The satisfaction rating from patients increased from 48 percent to 65 percent in the intervention clinic, compared with a jump from 50 percent to 59 percent in the controls. Patients were particularly pleased with access. Satisfaction with urgent appointment scheduling increased from 12 percent to 53 percent in the intervention clinic, compared with an increase from 14 percent to 18 percent in the control clinic. 

 

The composite satisfaction score for residents went up from 39 percent to 51 percent in the intervention clinic but fell in the control clinic from 46 percent to 42 percent.

 

The study noted that emergency room and hospital visits were not reduced.

 

"This was an anticipated finding, because we expanded access to care to an underserved patient population, and frequently when this happens, there's a spike in emergency and hospital room utilization," said study co-author Dr. Arek Jibilian, assistant professor of clinical medicine in the Keck School's division of geriatric, hospital, palliative and general internal medicine. "However, we believe that a sustained commitment to primary care will ultimately reduce emergency and hospital utilization, and this is something we hope to see as the program continues."

 

Study co-authors are Steven Asch, Arek Jibilian, Bharat Chaudry, Ron Ben-Ari, Eric Hsieh, Margaret Berumen, Shahrod Mokhtari, Mohamad Raad, Elisabeth Hicks, Crystal Sanford, Norma Aguirre, Chi-hong Tseng, Sitaram Vangala and Carol M. Mangione. Additional contributors include Becky O'Neal and Roman Corral.

 

The demonstration was primarily funded by the UniHealth Foundation in Los Angeles. In addition, the study was funded by grants from the Robert Wood Johnson Clinical Scholars Program; the U.S. Department of Veterans Affairs (grant 67799 to UCLA); the UCLA Resource Centers for Minority Aging Research Center for Health Improvement of Minority Elderly (RCMAR/CHIME) under NIH/NIA Grant P30-AG021684; and the NIH/NCATS UCLA CTSI (grant UL1TR000124).

 

The Keck School of Medicine of USC , founded in 1885, is among the nation's leaders in innovative patient care, scientific discovery, education and community service. It is part of Keck Medicine of USC, the university's medical enterprise, one of two USC-owned academic medical centers in the Los Angeles area. This includes the Keck Medical Center of USC, composed of the Keck Hospital of USC and the USC Norris Cancer Hospital. The two world-class, USC-owned hospitals are staffed by more than 500 physicians who are faculty at the Keck School. The school today has more than 1,500 full-time faculty members and voluntary faculty of more than 2,400 physicians. These faculty direct the education of approximately 700 medical students and 1,000 students pursuing graduate and postgraduate degrees. The school trains more than 900 resident physicians in more than 50 specialty or sub-specialty programs and is the largest educator of physicians practicing in Southern California. Together, the school's faculty and residents serve more than 1.5 million patients each year at Keck Hospital of USC and USC Norris Cancer Hospital, as well as the USC-affiliated Children's Hospital Los Angeles and Los Angeles County+USC Medical Center. Keck School faculty also conduct research and teach at several research centers and institutes, including the USC Norris Comprehensive Cancer Center, the Zilkha Neurogenetic Institute, the Eli and Edythe Broad Center for Stem Cell Research and Regenerative Medicine at USC, the USC Cardiovascular Thoracic Institute, the USC Eye Institute and the USC Institute of Urology.

 

General Internal Medicine and Health Services Research is a division within the department of medicine at the David Geffen School of Medicine at UCLA. It provides a unique interactive environment for collaborative efforts between health services researchers and clinical experts with experience in evidence-based work. The division's 100-plus clinicians and researchers are engaged in a wide variety of projects that examine issues related to access to care, quality of care, health measurement, physician education, clinical ethics and doctor–patient communication. The division's researchers have close working relationships with economists, statisticians, social scientists and other specialists throughout UCLA and frequently collaborate with their counterparts at the RAND Corp. and Charles Drew University.

 

The Robert Wood Johnson Foundation Clinical Scholars program has fostered the development of physicians who are leading the transformation of health care in the United States through positions in academic medicine, public health and other leadership roles. Through the program, future leaders learn to conduct innovative research and work with communities, organizations, practitioners and policymakers on issues important to the health and well-being of all Americans. This program is supported in part through a collaboration with the U.S. Department of Veterans Affairs.

http://newsroom.ucla.edu/portal/ucla/patient-centered-medical-home-248773.aspx

Community-Oriented Pediatric Medical Homes

Dr. Genevieve Daftary, Pediatrics Department | 9/15/2013, noon

A pediatric patient and his mother talk with a medical assistant at Codman Square Health Center. CODMAN HEALTH SQUARE

A Special Advertorial Section

What does a patient centered medical home (PCMH) look like within primary care pediatrics? What is needed from a pediatric- centered medical home within the context of an urban community health center like Codman Square? Our health center achieved the highest tier of recognition from the National Committee for Quality Assurance in 2012, reflecting our commitment and organizational capacity to provide care that is coordinated, patient centered and responsive to health of the population.

The process of achieving PCMH recognition was a reminder that children are not little adults. Our pediatric population struggles with the affects of asthma, obesity, sickle cell disease and attention deficit disorders, all considered chronic medical conditions within children. However, the management of these conditions and the more common issues affecting children and young adults of language delay, school and learning problems, high risk sexual behaviors, drug use and mood disorders do not typically fit well in the model of chronic disease management and episodic health care encounters that has been used in adult settings. If our aim is to be patient centered, how do we design a medical home that addresses these very important needs of the youngest members of our community?

It is interesting to revisit this question when one considers that the American Academy of Pediatrics (AAP) released one of the earliest concepts of patient centered medical home in its 1992 policy report on Medical Home. “The AAP believes that the medical care of infants, children and adolescents ideally should be accessible, continuous, comprehensive, family-centered, coordinated and compassionate.”

This initial policy statement grew out of almost 30 years of work by the AAP on addressing the care of children with special health care needs (CSHCN) and went on to inform more contemporary versions of this concept. This concept of the medical home was revised and expanded on by a coalition of the AAP, the American Academy of Family Physicians, the American College of Physicians and the American Osteopathic Association in 2007 and released as the Joint Principles of the Patient Centered Medical Home. Ultimately the Agency for Healthcare Research and Quality definition emerged and has largely been used to make decisions about accreditation.

While PCMH emerged from pediatrics and the care of CSHCN, the large majority of pediatric patients, both in our population and more broadly, do not have complex medical needs but do have complex social, developmental and psychological needs that have a large impact on their overall wellness now and in the future.

At Codman Square Health Center we have begun to structure a broader community-oriented perspective on patient-centered medical homes for children. We have done this internally using group visit models for children between birth and one year that emphasize shared community and parenting experiences and allow more time with providers to focus on anticipatory guidance. Additionally, we have incorporated the Project LAUNCH program into our support services for families most in need.

This federal grant has allowed us to have a family resource specialist and an early childhood development specialist available within the health center to support those families and children we identify as being most in need of parenting support, behavior coaching, child care resources and developmental assessments and support. These specialists have performed home and school visits, coordinated resources for families whose children are being evaluated for autism and helped coach young families struggling with homelessness, unemployment and single parenthood.

Externally, we have cultivated strong relationships with schools, recognizing that after early childhood, schools become not just the places where children spend most of their waking hours but also micro-communities that serve as a way to engage with students and parents around a variety of health and wellness topics. We enjoy being a resource for consultation on school health policies and programs, a referral resource for health services and an on-site provider of care.

Our longest and strongest partnerships have been with Tech Boston Academy, where one of our nurse practitioners runs a school-based health center, and Codman Academy Charter Public School, the first and only co-located school within a health center in the country. These relationships with schools fit into a belief that integrating education and health care can achieve real community wellness through the reversal of the effects of systemic poverty. As we work with these and other school partners, we are looking to build systems to promote the growth of healthy children who will go on to be leaders of healthy communities. It is a vision for a new patient-centered approach that we are excited to be a part of building.

Codman Square Health Center

637 Washington St, Dorchester, MA 02124

617-825-9660 | codman.org

http://baystatebanner.com/news/2013/sep/15/community-oriented-pediatric-medical-homes/?page=2

Researchers Create New 'Education-Centered Medical Home' Teaching Model

August 26, 2013 02:46 pm Sheri Porter – Researchers at the Northwestern University Feinberg School of Medicine in Chicago confronted two opposing truths back in 2011. The AAFP-supported patient-centered medical home (PCMH) model of care -- a team-based model that features easily accessible, high-quality health care coordinated by a primary care physician -- was gaining popularity nationwide as a means of improving patient care and lowering health care costs, but few medical schools were introducing PCMH concepts to students via curricular changes.

As a result, researchers set out to test the feasibility of a longitudinal clerkship based on PCMH principles and anchored by PCMH educational objectives. Researchers developed a model they dubbed the "education-centered medical home" and enlisted 56 student volunteers and four faculty preceptors from the medical school to participate in a study from June 2011 to April 2012.

The overall objective, according to study authors, was to "assess the feasibility and perceptions of an education-centered medical home clerkship on students and preceptors."

At the study's conclusion, program evaluations completed by participants revealed that students gained confidence in their understanding of PCMH principles and, in particular, appreciated experiencing early clinical exposure, continuity of care with patients and peer teaching. Faculty members also responded positively. In fact, all preceptors and 39 of 42 non-graduated students said they wanted to continue participation in the education-centered medical home clinics in the 2012-13 academic year.

STORY HIGHLIGHTS

• Researchers at Northwestern University Feinberg School of Medicine tested the feasibility of a longitudinal clerkship based on patient-centered medical home (PCMH) concepts and anchored by PCMH educational objectives. 
• They created an "education-centered medical home" model and enlisted 56 volunteer medical students and four physician preceptors to participate in a study from June 2011 to April 2012. 
• Students liked the early clinical exposure, continuity of care and peer teaching experiences; all four preceptors and 39 of 42 non-graduated medical students wanted to continue participation in the model. 

The research is summarized in an article titled "The Patient-Centered Medical Home as Curricular Model: Perceived Impact of the 'Education-Centered Medical Home'(link.springer.com)" in the August 2013 issue of the Journal of General Internal Medicine.

Program Setup

For purposes of the study, education-centered medical homes were established at four existing faculty practices. Two of the clinic sites are federally qualified health center family medicine clinics, another is an academic general internal medicine clinic, and the fourth is an academic pediatric pulmonary clinic. Student teams were formed with first-, second-, third- and fourth-year medical students on each team. High-risk patients were recruited in each setting. Clinical education was achieved via a traditional physician preceptor model with the additional component of third- and fourth-year students directly observing first- and second-year students. All students attended monthly grand rounds conferences.

Curriculum was developed with three objectives in mind. Researchers aimed to

• maximize student continuity experiences with patients, preceptors and peers;
• demonstrate patient-centered care principles of the PCMH model; and
• incorporate students in the delivery of PCMH care as health coaches and coordinators.

Researchers said the implementation of the education pilot at the Feinberg School of Medicine was a success and announced plans to expand the model in the 2012-13 academic year. They also acknowledged the study's limitations. For example, the authors said establishment of an education-centered medical home "would require significant financial resources and a substantial number of preceptors to incorporate all students at an institution."

Corresponding Author Answers Questions

AAFP News Now asked corresponding author Daniel Evens, M.D., an assistant professor of medicine-general internal medicine and geriatrics at Northwestern University Feinberg School of Medicine to answer a few questions about the project.

Q. What drove your interest in giving medical students training in a PCMH setting?
A. My career path as a "hybrid" ambulatory/hospitalist physician has placed me three months per year on our inpatient teaching service and the rest of the year in the clinic as a primary care physician. As a result, I recruited a large number of medically complex patients to my panel, and I have learned the hard way how difficult it is to coordinate care for these patients with chronic illness.

I've come to appreciate that there is no way that I can do it alone, and that I need a team to help me manage these patients. I also learned that medical students are eager to have continuity with complex patients and are willing to help with service learning projects.

During our recent curriculum renewal at Feinberg, we floated the idea of merging the needs of our primary care docs (e.g., the need for care coordinators and health coaches for our complex patients) with the desires of our students (e.g., the desire to have continuity with a panel of patients and learn how to manage chronic illness) into a new educational model called the education-centered medical home.

Q. What do you make of the highly positive evaluations from participating students and preceptors?
A. The positive student reaction to our education-centered medical home was not a surprise to our steering group. We knew that the average medical student was graduating after four years having never seen a single patient back for a continuity visit, so we knew that any program focused on continuity would be well received. The major question before our steering group was whether or not we could we create a program that was feasible from the viewpoint of the preceptors, and our retention of 13 out of 13 preceptors from last year's program gives us tremendous confidence that we are on the right track.

Q. Did the findings hold any surprises for you and your colleagues?
A. We started with the model of 16 students per preceptor mainly out of convenience (it was a multiple of four, easy for organizing four classes of students) and out of necessity (our limited funding required a large student-to-preceptor ratio). However, we were delighted to learn just how impactful it was for our preclinical students to pair up and have third- and fourth-year students directly observing patient encounters as peer teachers. The peer teaching aspect of the education-centered medical home ended up being rated just as highly as the continuity aspect of the program, and this was a wonderful unintended consequence of our 16:1 preceptor formula.

Q. Can immersing students in the PCMH model via the education-centered medical home help drive students to primary care specialties?
A. It will take several years to find out if our education-centered medical home program impacts the career choice of our graduates. We certainly hope that placing students into high-functioning primary care clinics that are committed to practice transformation will inspire some students to become medical home leaders themselves. Just as important, we hope that our graduates who still choose (sub)specialty practice will have a better understanding of the scope of primary care medicine and will be better prepared to be collaborative medical neighbors in the future.

Q. What's the most important take-away message from this project?
A. There is a large appetite among our students for continuity experience and the opportunity to learn about the medical home model. Our trainees are excited to work in the PCMH environment, and medical educators need to advocate on their behalf to create opportunities to involve them in practice transformation activities. For our part, we are happy to collaborate and share teaching materials with other institutions who are considering similar programs.

http://www.aafp.org/news-now/education-professional-development/20130826edumedhome.html