Playing for Prevention: Innovative Education for your Patients

It is estimated that 1 in 3 American adults have high blood pressure, and now face increased risks for chronic kidney disease, stroke, and heart attack/heart failure.

Given its severe impact on patient health, its high prevalence, and the low control rates (more than half of Americans with HBP do not have it under control), mHealth Games hopes to give a voice to this national health problem and improve the detection, awareness, prevention and treatment of hypertension and its consequences.

By supporting initiatives to improve patient outcomes, promote mobile engagement, and provide free education and services to patients and health care professionals, mHealth Games aims to advocate on behalf of all stakeholders with a focus on achieving fluency in the language of prevention.

This new game is an innovative twist on the standard "Hypertension Handout"

Mission Possible Identify and Eliminate High Blood Pressure

It is estimated that 1 in 3 Americans have high blood pressure, and 30% haven't even been diagnosed. This mission will prepare you to identify and eliminate hypertension. Do you accept?

If so, click the launch button below:

Launch Game

Medical Economics: Steinberg’s practice is textbook example of patient-centered medical home

Journal features Commonwealth Medicine physician leader

By Jennifer Rosinski

UMass Medical School Communications

June 05, 2014

The care coordination of an AIDS patient and his HIV-positive wife managed by UMass Medical School’s Judith Steinberg, MD, MPH, is a textbook example of success using the patient-centered medical home (PCMH) model, according to a cover story in the most recent issue of Medical Economics.

Dr. Steinberg (at right), clinical associate professor of medicine and deputy chief medical officer for UMass Medical School’s Commonwealth Medicine division, said that it was critical to have a behavioral health specialist immediately begin counseling the couple following their diagnosis.

That coordination would not have existed if Steinberg’s practice was not a medical home, one of 44 participants in the multi-payer Massachusetts Patient-Centered Medical Home Initiative (MA-PCMHI) sponsored by the Massachusetts Office of Health and Human Services.

“When I describe the patient-centered medical home to practices, providers, or to anyone—all of us are patients at one point or another—I like to say it’s really the way we, as patients, would like to see our care delivered,” Steinberg told Medical Economics.

“It makes such perfect sense that our care is focused on us as an entire individual, not as individual diseases or organ systems. That our care is well-coordinated and communicated across many settings and there’s an attention to quality and we are all partners in our care.”

The article, “Patient-centered medical home: Making care coordination work for your practice,” also included insight from Christine Johnson, PhD, PCMH quality improvement and transformation director at Commonwealth Medicine. She described how a physician reluctant to use care managers grew to appreciate them after they assisted in handling a complicated post-hospitalization patient. The physician said it was like “going from baggage to first class,” Johnson said.

Commonwealth Medicine is leading the development of the patient-centered medical home model and helping practices turn it into a reality. Led by Steinberg, Commonwealth Medicine has partnered with Bailit Health Purchasing LLC on MA-PCMHI. The three-year multi-payer demonstration concluded on March 31, 2014 and is in the analysis stage. Early results show 43 of 44 practices received National Committee for Quality Assurance PCMH recognition. Statistically significant improvement was shown in 11 of 22 clinical quality measures, including chronic disease management, prevention and care coordination. A complete evaluation and report is expected in the fall of 2014.

http://www.umassmed.edu/news/news-archives/2014/06/Medical-Economics-Steinbergs-practice-is-textbook-example-of-patient-centered-medical-home/

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

It’s Time for Episode-Based Health Care Spending

by Adi Kumar, Thomas Latkovic, and Daniel Tsai  |   1:00 PM October 8, 2013

There is widespread agreement that if the United States is to achieve sustainable levels of health care spending, it must make greater use of payment mechanisms that reward physicians, hospitals, and health systems for the results achieved. The vexing question is how best to make this transition.

Today, payers and providers are using a range of strategies to accomplish this goal, including patient-centered medical homes, value-based contracting, and accountable care organizations (ACOs). We applaud this trend. However, our research and experience have convinced us that the transition to outcomes-based payment will occur more easily if both payers and providers take an intermediate step and make greater use of retrospective episode-based payment (REBP).

REBP focuses on “episodes of care” (any clinical situations that have relatively predictable start and end points such as procedures, hospitalizations, acute outpatient care, and some treatments for cancer and behavioral health conditions). REBP identifies which provider is in the best position to affect the clinical outcomes and total costs associated with an episode of care; it then assesses (through retrospective analysis of claims data) the outcomes achieved and costs incurred during each episode over a specific period of time (e.g., quarterly). The identified providers are then rewarded or penalized based on their average performance across all the episodes.

The desire to jump straight to outcomes-based payment models focused on the total cost of care for an entire population has led many payers and providers to overlook, or give up on, episode-based payment. We believe it is worth reconsidering.

The Advantages

REBP offers a number of advantages. For example, because it uses the current fee-for-services claims system as its administrative platform, it does not require providers to make significant investments in new infrastructure or establish new contractual arrangements with other providers. And because it focuses on acute episodes, REBP acts as a necessary complement to payment and care-delivery models designed to improve prevention and chronic-care management. Furthermore, administering and/or participating in an REBP model can help both payers and providers develop many of the capabilities they will need for total-cost-of-care management. In short, REBP can serve as a bridge to more comprehensive total-cost-of-care approaches.

How Does REPB Work?

In the U.S. health system today, a dozen or more providers may be involved in an episode of care, and each provider typically bills separately. None of these providers is rewarded financially for helping ensure that the desired clinical outcome is delivered with the highest quality at lowest cost across the entire episode.

REBP is designed to change that. It is somewhat similar to and shares many of the same goals as the “prospective bundled payment” approach, which calls for making a single payment (or budget) to the accountable provider for all the services used to treat each specific episode for each specific patient. But key differences in design and administration make REBP more scalable in the current U.S. health system.

The six core steps required to implement REBP are listed in the exhibit “Steps Required to Implement REPB.”

Why Should Payers Pursue REBP?

Our analysis of data from private insurers, Medicaid, and Medicare suggests that 50% to 70% of all health care spending could be included within episodes of care. REBP establishes end-to-end accountability for more than half that spending.

REBP also gives payers a direct way to incentivize providers to reduce health care waste. We have consistently observed that some providers deliver the same or better clinical outcomes at dramatically lower costs than other providers in the same market. The exhibit “Average Cost Per Episode Varies Significantly Across Providers” illustrates variations in average, total per-patient costs for three different episodes in three different states. Even after we excluded patients with certain complicated conditions and adjusted for patient severity, the average cost per episode in each market still varied from 60% to over 300%. Further analysis showed that much of this variation could be explained by differences in practice patterns (e.g., decisions about device selection, diagnostics use, discharge planning, hospital admission).

REBP also offers a quick path forward, because it requires only modest additional infrastructure. We have seen multiple payers define and implement the necessary infrastructure within six months of when they agreed on an episode’s definition. Turnkey analytic vendors are also beginning to emerge.

In addition, REBP gives payers considerable strategic flexibility. Many REBP parameters can be adapted to address local conditions, align with network and member-engagement approaches, and strengthen competitive advantage. Among these parameters are cost thresholds, stop-loss provisions, the degree of gain- and risk-sharing, whether and how to normalize unit prices, and whether to steer members to certain providers.

Finally, REBP gives payers a way to prepare for the future, when episode-based performance management is likely to be a required capability. Most providers do not have access to sufficient claims data to assess performance on their own. If providers are to accept partial or total cost-of-care accountability, payers will need to offer them a performance-management infrastructure to understand clinical outcomes and costs.

Why Should Providers Pursue REBP?

If contractual terms are fair, REBP can deliver meaningful value to acute-care providers in particular. For example, it has the potential to give them a net increase in margin, because many of the sources of savings are either variable costs to these providers (e.g., implantable devices, extra care required for surgical complications) or are associated with upstream or downstream providers (e.g., pharmaceuticals, physical therapy, skilled nursing facility care). REBP can also help acute-care providers reinforce and accelerate existing strategic priorities, such as improving how hospitals influence and partner with physicians, increase adoption of clinical pathways, and reduce input costs.

REBP empowers all accountable providers by reducing the need for payers to monitor clinical decision making (e.g., through preauthorization). It also positions them to assume a stronger role in influencing the performance of upstream and downstream providers.

Strong episode performance has the potential to strengthen a provider’s value proposition to patients, employers, and payers. It may also be grounds for negotiating a stronger network position.

Furthermore, REBP requires providers to make only small, if any, investments in new infrastructure — at least initially. And it will enable them to strengthen their ability to understand end-to-end performance, a capability any providers considering more holistic total-cost-of-care payment models will need.

What Changes Must Payers Make?

To implement REBP at scale, most payers will have to shift their focus from prospective to retrospective models in most markets. Doing so will enable payers to simplify their infrastructure and focus on analytic processes that are separate from claims adjudication. This infrastructure is less invasive, requires less investment, and offers faster time-to-market than do solutions that necessitate material changes to claims-adjudication processes.

Second, payers will need to develop greater technical sophistication to ensure fairness (e.g., through episode-specific risk adjustments) and provider acceptance. They will also have to develop or adopt new standards as they emerge. The Center for Medicare and Medicaid Innovation’s efforts to create standard episode definitions, including through the Bundled Payments for Care Improvement Initiative, are a promising starting point.)

Finally, if REBP is to succeed, payers will have to implement it at scale by promoting REBP, whenever possible, across all books of business and all network providers. Most payers should also strongly consider participating in multi-payer efforts to set standards to help overcome common barriers to implementation.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us at healtheditors@hbr.org, and sign up to receive updates here. 

http://blogs.hbr.org/2013/10/its-time-for-episode-based-health-care-spending/

Improving Health Care, Controlling Costs – Rutgers Launches New Initiative

One key factor sets Robert Wood Johnson Partners apart from other attempts at reform – the Accountable Care Organization has the power of a major research university behind it

Monday, October 7, 2013

By Andrea Alexander

Credit: Nick Romanenko

Nurse Donna Bonavitacola assists as Alfred Tallia examines Barbara Carcich.

'This is one of the first tangible benefits of how the new Rutgers is going to serve the state of New Jersey in health care. This was not possible before. Now we have all the pieces under one roof.' – Alfred Tallia

 

Meet the some of the collaborators and researchers behind Robert Wood Johnson Partners:

 

Lynn Clemow, a clinical associate professor in the RWJMS Department of Family Medicine and Community Health, coordinates a program to place graduate students from the Department of Psychology and the Graduate School of Applied and Professional Psychology at the Monument Square primary care practice. The graduate students work with patients to quit smoking, take their medicine and on more traditional mental health issues. "Mental health services are a nightmare of poor reimbursement and poor access,'' Clemow said. "This cuts through the stigma of seeking out services and having to call an 800 number, talk to a clerk about your issues and get a list of providers, many of whom arent taking patients or on the plan anymore, Clemow said. About 15 percent of patients recommended for mental health services outside the office make an appointment, but closer to 90 percent of patients do in an integrated system, she said. "Depressed people don't take as good care of themselves, they don't take their medications because they don't seem to have the energy to do that, Clemow said. "If you treat the depression, everything works better.''

 

Xiaomu Zhou, an assistant professor in the School of Communication and Information, wants to study how access to information through the patient portal can improve communication between patients and doctors. "I want to understand how information technology can be designed to provide more information access to patients, facilitate communication and lead to better health outcomes,'' Zhou said.

 

Professors Kang Li and Susan Albin, in the School of Engineering, will use mathematical modeling and statistical analysis to study workflow in the primary care office and define the role of a patient care coordinator. "The availability of services from a patient care coordinator could reduce patients frustration obtaining care, fulfill doctors’ plans for how best to help the patient, and reduce the cost burden on the whole community with fewer emergency room visits and hospital admissions,'' said Albin, a professor in the Department of Industrial and Systems Engineering.

One Rutgers, A World of Discovery

The new Rutgers, combining nearly 250 years of academic excellence with a renewed commitment to medical education, is inspiring faculty, students and staff to form innovative partnerships in academic research and public service. In an online series, Rutgers Today examines the new ways that members of the university community are collaborating, across a wide range of disciplines, to better meet the needs of the people of New Jersey and beyond.

– The Editors

During nearly three decades as a primary care physician, Alfred Tallia has identified a daunting list of flaws with the nation’s health care.

Specialists rarely coordinate care for patients with chronic illnesses such as diabetes and high blood pressure – which can lead to repetitive, expensive tests.

In most doctors’ offices, no one is responsible for developing plans with patients to lose weight, exercise and change their diet – or for following up with those patients to help them meet their goals.

But Tallia, chair of the Department of Family Medicine and Community Health at Robert Wood Johnson Medical School – now part of Rutgers – is getting ready to launch a solution he believes will deliver more effective care at a lower cost.  

“The idea of improving quality and controlling costs, that is something here to stay,’’ Tallia said. “We can’t keep spending 18 percent or more of the Gross Domestic Product on health care, not cover everybody and have disappointing outcomes. That is what we have now.’’

Tallia is spearheading the creation of an Accountable Care Organization, called Robert Wood Johnson Partners, that will coordinate treatment among doctors, other health professionals, and hospitals through better use of electronic health records. The project also involves restructuring doctors’ offices to improve communication with patients, and directly involve them in developing plans to benefit their health.

Although similar efforts have been rolled out around the country since health care reform became law in 2010, one key factor sets Tallia’s work apart :

Robert Wood Johnson Partners has the power of a major research university behind it.

Tallia and others in the medical school – in partnership with Robert Wood Johnson University Hospital and Health System – are teaming up with researchers across different disciplines at Rutgers to find the best ways to improve care and curtail costs. This includes the School of Engineering, the Department of Psychology, and the School of Communication and Information.

Credit: Nick Romanenko

Physician Alfred Tallia at Robert Wood Johnson Medical Group’s Family Medicine office at Monument Square.

 

“The reason for Robert Wood Johnson Medical School and Rutgers to be involved is to answer the many outstanding questions about how a system should work,’’ Tallia said.  “We are in the best position not only to deliver care, but to also do the research to make it better.’’

For example, a professor in the School of Communication and Information plans to study the use of a patient portal, an online information hub that would allow patients to access test results and other health information. The technology will also allow patients to schedule appointments, request or renew prescriptions, pay bills and ask questions about their care.

Graduate students from the Department of Psychology in the School of Arts and Sciences and the Graduate School of Applied and Professional Psychology will work in a primary care practice to help patients quit smoking, improve eating habits and address other behavioral health issues.

And professors in the School of Engineering will use mathematical modeling and statistical analysis to study workflow in the primary care office and define the role of a patient care coordinator. The person in this position would be dedicated to helping patients adhere to plans for their health – which could involve communicating with pharmacies to make sure prescriptions are filled, keeping tabs on exercise plans and coordinating appointments.

“Part of what the engineering department is going to do is help us make our care more efficient so we can spend more time on things that really matter,’’ said Elizabeth C. Clark, an assistant professor in the RWJMS Department of Family Medicine and Community Health.

“If doctors are spending less time doing paperwork they will have more time to spend with patients,’’ Clark said.

The medical schools, nursing, pharmacy, and other professional programs at Rutgers can also build on lessons learned to train a team-based workforce suited to meet the health care needs of the future, Tallia said.

Brian L. Strom, the incoming chancellor of Rutgers Biomedical and Health Sciences who is also a primary care physician, echoed concerns about the health care system and called Tallia a “national leader in this area.’’

“As a nation, we need to move away from an episode-based disease management system,’’ Strom said.

“This will require a multidisciplinary approach to population health, and a multidisciplinary approach to evaluating the new models of care that emerge, like the ACO planned by Dr. Tallia. Rutgers, with its depth and breadth across health and non-health fields, is enormously well positioned to be a leader in this field."

A Timeline for Providing Care

Robert Wood Johnson Partners is seeking approval to start treating Medicare patients early next year. The Affordable Care Act encourages the creation of such Accountable Care Organizations for Medicare patients, but most have been developed around hospital systems.

Rutgers would be one of the first academic institutions to launch such an organization, Tallia said.

Tallia is also talking to some of the state’s major health insurance companies including Horizon Blue Cross Blue Shield and Aetna to expand into a statewide organization next year called Rutgers Health Partners.

In the meantime, the Robert Wood Johnson Partners would be modeled on the restructuring of Rutgers Robert Wood Johnson Medical Group’s Family Medicine office at Monument Square in New Brunswick. The primary care practice, which is part of the Robert Wood Johnson Medical School, has been organized into a “patient-centered medical home,” where medical providers share information and work with patients to closely coordinate care.

Nearly 30 additional primary care practices have signed contracts to participate in the upcoming rollout of Robert Wood Johnson Partners.

The partnership would also include the 500 specialists in the Rutgers Robert Wood Johnson Medical Group along with clinicians on staff at Robert Wood Johnson University Hospital and the other hospitals within Robert Wood Johnson Health System.

Medicare and insurance companies offer financial incentives for such reform efforts that meet benchmarks for improving care while moderating costs. Participating doctors, hospitals, and other providers would receive a share of the savings. And in Robert Wood Johnson Partners, patients may also share in the benefit.

A Difference Patients Will Notice 

What this will mean for patients is seamless care, much like the experience Lou and Barbara Carcich have with the doctors at Monument Square, where some of the changes have already been introduced. When Barbara Carcich went for a follow up visit after a hospital stay, the doctor had all the information about her illness and treatment at his fingertips.

“I didn’t have to go through the whole thing again: why I went in, what happened,’’ said Carcich, of Somerset. “You know the information you usually have to retell, it was all there. My doctors in the hospital communicated and all care was coordinated with Dr. Tallia and his nursing team at Monument Square."

And Lou Carcich finds it reassuring that Tallia and his cardiologist receive the results of his blood work simultaneously. “I feel very confident and comfortable knowing that I have two doctors working for me who are both on the same page," he said.

What the Somerset couple doesn’t see is the coordination behind the scenes. Tallia and the cardiologist both have access to Lou Carcich’s electronic medical records. If there is an issue Tallia wants the cardiologist to look into, he can make a note in the record for the cardiologist.

Tallia and other members of his team are looking forward to forming new partnerships with faculty from other academic units and research institutes at Rutgers – including the College of Nursing, the School of Social Work, the Edward J. Bloustein School of Planning and Public Policy, Rutgers Center for State Health Policy and all the units of the new Rutgers Biomedical and Health Sciences – as Robert Wood Johnson Partners moves ahead.

“This is one of the first tangible benefits of how the new Rutgers is going to serve the state of New Jersey in health care,’’ Tallia said. “This was not possible before. Now we have all the pieces under one roof.’’

http://news.rutgers.edu/feature/improving-health-care-controlling-costs-%E2%80%93-rutgers-launches-new-initiative/20131006#.UlKy71CsiSp

Medication Management: Integrating the Pharmacist as the Champion

Jon Easter, BSPharm, RPh

Published Online: Thursday, August 8, 2013

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Pharmacists should solidify their place within the patient-centered medical home. Here is an early model that achieves better health outcomes through comprehensive medical management and a team-based approach.

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I have worked in the pharmaceutical industry for more than 20 years. At my core, I am a pharmacist by training, and have long had a passion for exploring ways to integrate pharmacy practice into care teams with a goal of improving outcomes and lowering the total cost of care.

For me, this quest began in the mid-1990s working in state government affairs for GlaxoSmithKline (GSK) in the Pacific Northwest on pharmaceutical care initiatives with local pharmacy associations and schools of pharmacy. As I moved into the US Public Policy group at GSK, my role transitioned to educating policy makers on the results and benefits of the Asheville Project (www.nbch.org/The-Asheville-Project-Case-Study) and eventually, to support a collaboration with the American Pharmacists Association Foundation to replicate the Asheville model through the Diabetes Ten City Challenge.

We haven’t been alone at GSK. Many leaders in the profession have worked tirelessly to elevate pharmacy practice as part of care coordination models. But challenges to date around payment for services, scope of practice, and a lack of technology needed to implement effective comprehensive medication management solutions have slowed the progress. However, to use an old cliché, there is light at the end of the tunnel. Today, the movement toward a value-based health care system in the United States represents an incredible opportunity for pharmacists, and most of all, for patients.

The United States health care delivery system is currently designed to focus on episodic care and acute illness. Most health care reform experts have articulated the need to improve the health care delivery infrastructure to enable better proactive management of chronic diseases and prevention services. However, implementing a better health care delivery system is interdependent on achieving payment reforms that align incentives to clinical outcome improvements, as well as connecting the care delivery infrastructure with health information technology, which facilitates the sharing of information and provides the needed quality data mining necessary for payment.

Improving the health care delivery system is a key, interdependent component of overall health care reform. One way to do this—coordinating the delivery of health care through a Patient Centered Medical Home (PCMH)—is gaining popularity among public and private payers as well as policy makers. The medical home model is gaining momentum because of its value proposition for the patient, physician, and payer by improving outcomes while lowering costs.

The medical home model is gaining strong political support as well. The 2010 Patient Protection and Affordable Care Act (ACA) contains several provisions relating to the PCMH. Most notable is the creation of the Center for Medicare and Medicaid Innovation (CMMI), which is piloting broad payment and delivery system reforms across the country. CMMI has launched 2 large demonstration programs, the Multi-Payer Advanced Primary Care Practice (http://innovation.cms.gov/initiatives/Multi-Payer-Advanced-Primary-Care-Practice/) and the State Innovation Models Initiative (http://innovation.cms.gov/initiatives/state-innovations/), both of which have a significant PCMH component.

In addition to the federal activity, most states understand the value of the medical home and several are currently implementing pilot programs. According to a recent Health Affairs (http://archive .pcpcc.net/2012/11/6/health-affairs-article-half-states-are-implementing-patient-centered-medical-homes), 25 states have enhanced provider payment systems to encourage implementation of the PCMH within their Medicaid program.

Unfortunately, of all the great care coordination work being done across the country, very few of these initiatives have included clinical pharmacists on the care team. Appropriate use of medications is a key element of a coordinated care delivery system, and in my opinion, pharmacists are the best suited to lead the effort to optimize therapy and help patients achieve their clinical goals.

Demonstrated Success with PCMH

Nowhere is the value proposition of the patient-centered medical home model more clear than at Community Care of North Carolina (CCNC), an organization with which GSK is proud to have a long history of collaboration.

CCNC (www.communitycarenc.org) began in 1998 in order to improve health care quality and save costs. The program now provides care to more than 1 million Medicaid recipients in North Carolina and has grown to encompass 14 networks, 4500 primary care physicians, and 1000 medical homes. According to a 2011 Milliman analysis, CCNC saved the state of North Carolina almost $1 billion between 2007 and 2010, primarily through lower emergency department and hospitalization utilization. The Healthcare Leaders Council awarded CCNC its Wellness Frontiers Award in April 2013 for implementing evidence-based care management programs that prevent disease and encourage wellness.

CCNC relies on patient-centered medical homes, population health management, case management services, and community-based networks to deliver care. The program provides each Medicaid recipient a case manager to serve as their coach to make sure they understand doctors’ orders and get to their appointments on time. CCNC has further developed their care coordination networks by adding several disease management initiatives, including asthma, diabetes, and congestive heart failure, as well as a chronic obstructive pulmonary disease pilot program.

Pharmacists began to work with CCNC on its medical home program in 2007 after it was noticed that there were patients with diverse medications who were prone to polypharmacy-related problems. It was evident that pharmacists could enhance clinical outcomes by providing medication management (pharmaceutical care) services while also managing drug costs. While medication cost savings are a convenient ancillary benefit to the program, the primary objective of CCNC pharmacy projects has not been to minimize medication costs, but rather to achieve therapeutic optimization to maximize health.

This is a subtle but important distinction since the former contributes toward the volume-based system we are moving away from while the latter allows for prescriber and patient-centered interventions such as coaching for adherence that in some instances actually increase medication costs, but ultimately improve care, when appropriate.

A team-based approach—pairing a pharmacist with the case manager—has been used so that an assessment of each patient can be made and points can be prioritized to inform the primary care physician before they see the patient face-to-face.

Throughout the CCNC networks, there are now more than 50 pharmacists who are the lead project managers and facilitators of pharmacy-related activities within a certain geographic boundary. They participate in activities such as developing proposals for new initiatives, reporting to the network leadership on existing initiatives, or presenting at local medical management meetings. The scope of activities in the CCNC networks offers a unique opportunity and challenge for pharmacists, and there is a growing need for more.

Pharmacist Role in Care Coordination

So where else are the pharmacists working within a PCMH environment? It seems obvious that one of the key areas of care coordination between a health care provider and the community is that of comprehensive medication management. To date, predictably, most pharmacists playing an integral “care coordination” role are located within the public integrated delivery systems, such as the Veterans Administration and Health Resources and Services Administration, as well as the private integrated delivery systems, such as Kaiser Permanente. Unfortunately, the “siloed” nature of ambulatory medicine has prevented significant uptake in pharmacist participation to date.

Fortunately, the Patient Centered Primary Care Collaborative (PCPCC) recognized this opportunity and organized a multi-stakeholder workgroup to formalize the role of the clinical pharmacist within the PCMH. That group published the second edition of “Integrating Comprehensive Medication Management to Optimize Patient Outcomes” in June 2012 for physicians, insurers, payers, and pharmacists to follow as they formalize the medication management relationship between a pharmacist and provider care coordinator.

Additionally, previously in 2009, Dr. Edwin Webb from the American College of Clinical Pharmacy authored a white paper entitled “Integration of Pharmacists’ Clinical Services in the Patient-Centered Primary Care Medical Home.” Dr. Webb references several recommendations of the Institute of Medicine’s “Quality Chasm” report, and based on those recommendations, he suggests pharmacist integration into the PCMH should be based on 7 essential principles. These principles emphasize the need for pharmacists’ clinical services in a patient-focused environment, as well as highlight the need for a flexible care delivery design that is focused on outcomes with access to HIT systems. The final principle calls for aligned payment policies to substantiate the medication management process.

Given the momentum to evolve our health care delivery and payment system to one that is proactive, coordinated, and connected, I cannot think of a better time for pharmacists to solidify their place within medical homes across the country. As pharmacists, we must step up if we are ever to demonstrate the critical role of comprehensive medication management in achieving better health outcomes and lowering overall health care costs. What an opportunity for us, and there is no time to waste—the patient is waiting.

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Jon Easter, BSPharm, RPh, is senior director, delivery and payment reform, at GlaxoSmithKline (GSK). His primary focus is health care transformation and the health information technology (HIT) policy environment, where he works to maximize its value to enable better health care quality, enhance the US health care delivery system, and ultimately improve patient outcomes. At GSK, Jon has championed the company’s involvement in North Carolina First in Health, one of the nation’s leading patient-centered medical home projects. He was also directly involved with replication of the Asheville Project, a recognized model for care coordination to improve patient outcomes for chronic disease. Jon has spent 20 years in the pharmaceutical industry. In addition to his public policy experience, Jon has implemented patient registry systems within GSK’s care management division, covered the Pacific Northwest for the state government affairs organization, and spent several years as a sales representative and district sales manager.

- See more at: http://www.pharmacytimes.com/publications/Directions-in-Pharmacy/2013/August2013/Medication-Management-Integrating-the-Pharmacist-as-the-Champion#sthash.cXCNPpDW.dpuf

Preparing for the medical home transformation

August 07, 2013 | Pam Minichiello - Project Director, MAeHC; Courtney Beach - Practice Consultant, MAeHC

Photo used with permission from Shuttershock.com

Medical homes are considered one of the most promising experiments under way to improve the quality of care and lower costs. The concept has been gaining momentum and shows no signs of slowing.

The principles of the medical home model aren’t new and are geared to ensure that patient-centered care is comprehensive and coordinated, and that it enhances patient access and focuses on the provision of quality and safe care.

The concepts of the medical home require a team-based approach that utilizes health information technology to identify and assist with the management of patient populations while allowing for the measurement of clinical outcomes. Although many of the principles and concepts of the medical home model are part of the day-to-day operations of the small primary care practice, the full adoption of the model can appear overwhelming. Solo practitioners and small practices must deal with a combination of scarce staff resources, small operating budgets and large demands to meet volume targets under fee-for-service payment. Those factors make it less feasible for small practices to hire extra staff (such as a nutritionist, data analyst or care coordinator) to support and sustain the transformation.

Although these barriers are real, they are not insurmountable. With appropriate planning and development, a small practice can achieve a successful medical home transformation. The following areas deserve attention if your practice is considering pursuit of medical home status:

Practice education – It’s important that each member of the practice care team fully understand the concept and principles of a medical home. This knowledge drives buy-in and promotes active participation in the successful transformation.

Practice roles -- Utilize limited resources to maximum abilities and scope. First identify what each team member is currently responsible for and look for opportunities to align responsibilities across the team to match skill sets. It’s important to utilize each staff member to his/her fullest capabilities in this team-based approach.

Care team responsibilities – Clearly define the role each team member will play in the medical home and develop the processes that support the following medical home concepts:

• Patient tracking and follow-up;
• Patient and caregiver education;
• Health promotion and wellness care;
• Care coordination;
• Clinical outcome and performance monitoring; and
• IT support and EHR system management and configuration.

Relationships within the medical neighborhood – Identify the community resources outside of the practice that provide specialty care, care management, hospital services, home care and behavioral healthcare. You must be able to coordinate and effectively manage your patients’ care. Establish formalized relationships with these resources to define referral protocols and follow-up processes, as well as admission and discharge coordination services. Think in terms of streamlining these processes.

Enhanced payment programs – Many payers across the country offer enhanced reimbursement for primary care providers that receive NCQA PCMH recognition with the purpose of providing financial support to assist the small practice in increasing necessary staff and services to support the medical home.

EHR configuration and utilization -- The cornerstone to success is to ensure your EHR is working for you. Having an in-depth understanding of how your EHR works and flows is key to streamlining clinical processes in the office. In addition, configure your system to provide meaningful care alerts, pertinent decision support, patient education materials and customized documentation templates to optimize workflow.

Health information exchanges – An HIE can serve as an excellent resource for collecting comprehensive clinical information for your patient population. HIEs build a “community record” of sorts; that record aggregates the pertinent information from specialists and hospitals, provides diagnostic testing results geared to quickly give primary care practitioners the information needed to assist in managing their patients’ care.

Engaging the practice to make a “system-wide” transformation can be challenging, but with appropriate planning and development the small practice can successfully transform into a true medical home.

Pam Minichiello is project director for the Massachusetts eHealth Collaborative (MAeHC). Courtney Beach is a practice consultant with MAeHC.

http://www.physbiztech.com/best-practices/business/preparing-medical-home-transformation