Archive for the ‘Patient-Centered Medical Home’ Category

How to Engage Specialists in the Patient-Centered Medical Home

April 1st, 2014 by Patricia Donovan

Primary care's relationship with specialists will influence quality and reimbursement.

Florida Blue's primary care focused pay-for-performance program transitioned in 2012 into a statewide patient-centered medical home (PCMH) initiative. Here, Barbara Haasis, RN, CCRN, senior clinical lead for quality reward and recognition programs at Florida Blue, describes the role of primary care in engaging specialists in the PCMH program.

Engagement of specialists happens through the primary care physician (PCP). The PCP will be judged on the total cost of care, and his percentage of the shared savings is based on working with specialists that are efficient, and that report back to him or her, so that they are aware of what is going on. That is the development between the PCP and the specialist. They have to go to a specialist in the network, but we are not specifying who.

There is a huge incentive for the PCP, because when we look at a member’s total cost of care, we are looking at inpatient/outpatient, specialty, primary, lab, x-ray, total cost of care—it is everything. If there are two specialists, and one orders every test under the sun, whether it is needed or not, and the other goes into the ER to see the member and takes care of them efficiently and effectively, that primary care doctor is going to change his referral pattern to go to the more efficient. That is the incentive.

We are setting up other arrangements with specialists that will marry up to the PCMH. For example, we may do some kind of preferred cardiology network in the Orlando area into which the PCPs will probably refer. We cannot do that here. We have contractual language with many of our facilities and physicians that prevent us from doing any steerage.

It is up to the physicians to work through relationships to find the most effective for their practice.

Excerpted from: New Models in the Patient-Centered Medical Home: Incentives, Infrastructure and IT to Support Accountable Care

8 Challenges to Medical Home Success

March 12th, 2014 by Jessica Fornarotto

"What's important about patient-centered medical homes (PCMHs) is that they're patient-centered. PCMHs are a partnership among practitioners, patients and their families that ensures and respects the decisions of the patients. And patients have the education and support they need," explains Terry McGeeney, MD, MBA, director of BDC Advisors. Dr. McGeeney lists below the eight challenges in successfully changing to a PCMH.

The first challenge to PCMH success is that many physicians are reluctant to change. Physicians have been trained to be change-averse and variable-averse to avoid making mistakes at two o’clock in the morning, etc. Second, physician leadership and physician champions are critical. Sometimes this has to be trained and taught.

Next, there's a culture that is very traditional in healthcare; we need to think and talk about that. There is also a culture within individual practices and health systems that creates barriers to successful transformation. Another challenge is that some providers are not able to function effectively in a team environment. This needs to be supported and transformed with the appropriate training provided.

The next challenge is communication, which is critical at multiple levels. Successful medical neighborhoods and clinically integrated neighborhoods (CINs) are built around communication, care plans, care that's delivered, data, quality metrics, lab data, etc. The sixth challenge is that there has to be trust between all of the entities as systems are transforming and payor data becomes more critical. Partnerships with payors around shared savings or shared risk are becoming more common. Trust is critical and that hasn’t always existed.

Next, we need to make sure there are aligned incentives; you can't ask people to do more work for the same compensation. You can't ask them to assume more risk for the same compensation. Incentives need to be aligned around what is now called 'value-proposition' or 'pay-for-value,' or to where there is an expectation to improve quality and lower cost.

The final challenge is there needs to be full recognition that PCMH transformation is not easy. It's very difficult and time consuming, but in the end it's highly rewarding.

Excerpted from: Driving Value-Based Reimbursement with Integrated Care Models

Medical Neighborhood Bridges Gap Between Health Systems and Physicians

February 18th, 2014 by Patricia Donovan

The medical neighborhood is one approach to defragmenting care coordination in the United States.

The need for better coordination within the U.S. healthcare system cannot be refuted, notes Terry McGeeney, MD, MBA, director of BDC Advisors, who introduces the trend toward medical neighborhoods.

We need to start talking about the solution to bridge the gap between health systems and physicians. We can do that as we talk about the medical neighborhood concept and the integrated network concept. I have come to realize that the medical neighborhood in many environments is a physician term that’s been embraced widely by both specialty organizations and primary care organizations.

A clinically integrated network (CIN) is a hospital term. These CINs have been around since the late nineties, when they were established by the Federal Trade Commission (FTC) and Federal Communication Commission (FCC). And you will often hear hospitals talking about clinical integration. The difference is that until the last couple of years, clinical integration has often been within the four walls of the hospital, where now it’s being expanded to broader networks around population management.

What are these medical neighborhoods that we are talking about and where are they? When you want to look for a medical neighborhood, look no further than your CIN for the foundation of that network. The challenge you often see is that the CIN or clinically integrated entity was set up as a legal entity and is not necessarily a high functioning medical neighborhood. It may have been set up by a law firm, or an accounting organization. It meets all the legal requirements, but it may not meet the requirements needed for improving quality of care in lowering cost.

But that existing CIN does create a foundation from which you can work. What you want to work and think about is transitioning your clinically integrated entity to a high functioning medical neighborhood. And to me that’s the real opportunity, but also a significant challenge.

Excerpted from: Driving Value-Based Reimbursement with Integrated Care Models

Top Tools, Workflows and Processes for a Patient-Centered Medical Home

February 4th, 2014 by Patricia Donovan

Online tools such as EHRs and registries facilitate care coordination in the patient-centered medical home.

Chart scrubbing, electronic medical records and disease registries form the framework of patient-centered care, according to respondents to the 2012 Patient-Centered Medical Home survey. The following tools, workflows and processes are enhancing patient-centered care delivery by responding organizations, as told in their own words:

  • Added patient advisory council, which has made great suggestions.
  • ‘Electronic medical record (EMR) lite’ with secure e-mail.
  • Extended hours obviating urgent care centers or ER visits.
  • Chart scrubbing: review of the charts of patients coming in for appointments so that the provider is made aware of everything that needs to happen at that visit so it can be taken care of proactively.
  • Microsystems.
  • Registry management.
  • Using lower level (education) workers in the process.
  • Patient profile to include all providers, specific care gaps, etc.
  • Discharge reconciliation registry.
  • Our EMR is the most effective; it supports everything else. Secondly, standardized written protocols/standing orders that allow the healthcare team to provide care that increases office efficiency and quality indicators.
  • It’s not about the tools, it’s about training the people to use the tools effectively and efficiently. ‘LEAN’-ing is not a cure; it’s another aspect of training.

Excerpted from: 33 Metrics for Care Transition Management

4 Trends for Healthcare Providers in 2014

January 30th, 2014 by Jessica Fornarotto

Dual-track medical homes, e-visits, retooled patient handoffs and more post-acute care are predicted provider trends for 2014, according to Steven Valentine, president of The Camden Group. HIN interviewed Valentine prior to his presentation during an October webinar on Healthcare Trends & Forecasts in 2014: A Strategic Planning Session.

HIN: What is the physician practice going to look like in 2014? How has the primary care team evolved to meet the Triple Aim values inherent in the PCMH and accountable care models?

(Steven Valentine): We should expect to continue to see consolidation amongst the medical groups. The independent practice associations will begin to assimilate together because they need to put more money into their infrastructure. And many of the organizations have underperformed, in all honesty.

The primary care team is still critical. We've benefitted by keeping many primary care doctors around because they were negatively hurt with their net worth in the recession in 2008-2010. But it's slowly coming back and we’re starting to see those physicians thinking about retirement again. The reality is, we're never going to replace all of these primary care doctors as they wind down their practice. We need to do a better job of getting telehealth going and utilizing e-visits. We're seeing the health plans starting to pay for those e-visits, as well as having the consumer who uses them use a credit card and pay at that time, just like a visit.

We're going to have to look at different models. Obviously, the nurse practitioner is getting more involved with the primary care. And yes, they're still pursuing the Triple Aim. We know that quality scores, satisfaction scores and trying to manage cost per unit is still a critical focus of the triple aim moving forward with population health.

Lastly, with a PCMH in accountable care, while some of the pioneer accountable care organizations (ACOs) reduce themselves out of pioneer into the Medicare Shared Savings Program (MSSP), we still have a number of organizations and it's growing. The commercial ACOs have been very successful in California.

We fully expect accountable care to continue. We think the PCMH will evolve into two tracks. The first track is a primary care PCMH. The spinoff is a chronic care medical home that has the multidisciplinary team organized around a chronic disease. This is a model developed by CareMore years ago in Southern California and it's been expanded across the country. As I travel the country, I run into organizations that have set up these chronic care centers around the chronic disease.

HIN: Regarding the Pioneer ACO program, one of the top performers in the CMS pioneer program, Monarch HealthCare, told us that it's going to be working to engage specialists in care coordination roles in year two and year three. What's ahead for specialists in terms of quality and performance improvement as well as shouldering perhaps more care coordination duties, especially for Medicare patients?

(Steven Valentine): The specialists are going to be a critical piece to this whole solution. They have been a tremendous asset in the area of bundled payments, where you have the facility fee and physician fee combined into one payment. That works for both the Medicare as well as the commercial side. You're beginning to see more of the bundled payments within an ACO.

The ACO manages what we call 'frequency' — in other words, the number of procedures to be done. Specialists are involved in satisfaction, quality scores, and resource consumption once the decision is made that the procedure needs to be done.

We expect the specialists to be involved with quality and performance. Everybody is putting in incentive programs to help drive higher quality, better performance, and a lower cost.

HIN: Hospitals have tightened the patient discharge process as a means of shoring up care transitions. But what other work needs to be done in terms of collaborations, perhaps with skilled nursing facilities (SNFs), long-term care and home health, for example, to improve patient handoffs and reduce hospital readmissions?

(Steven Valentine): Handoffs have probably been one of the areas where we've seen the most disappointment or underperformance within many ACOs. They have not effectively involved the hospitalists and the care/case managers who are typically embedded within the medical group that would oversee the patient throughout the care continuum. Or if it's a health system, emanate centralized care/case management function where they manage all of the transitions from pre-acute, acute to post-acute. We think this will get better. As the doctors are more at risk, they will get more engaged with the care/case managers to manage these transitions and handoffs.

We also know that, while not in 2014 but the trend will start, we'll see lower acute care utilization, pushing more patients to post-acute care. This means, in any given area, acute care hospitals will begin to convert excess capacity to post-acute care services like skilled nursing, long-term care, palliative care, hospice care, home care and rehab care. You will begin to see a closer proximity. The care managers will be able to work more effectively with the doctors and hospitals to manage the patient through the continuum, smooth out these transitions and have a better patient experience with better satisfaction scores at a lower cost.

Excerpted from: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry

Adapting 3 NCQA Standards for the Patient-Centered Medical Home

January 24th, 2014 by Cheryl Miller

Coming from a group of innovators who had adopted EHRs early on and were not afraid of data, participants in the Hudson Valley medical home transformation project decided to concentrate on three out of nine NCQA standards: access and communication, inpatient self-management, and performance reporting, explains Paul Kaye, MD, medical director at Taconic IPA.

Let’s move on to the nine standards of NCQA. All of them are available at NCQA’s Web site. We found that we needed to concentrate primarily on the areas of access and communication, inpatient self-management and performance reporting. It’s not to say that the other pieces don’t warrant a challenge, but many of them reflected EHR use and the ability to report on that use rather than a radical transformation of practice.

Initial steps were to require all of our practices to take TransforMED’s medical home IQ self-examination. Then a practice work plan for each practice was created. There was a staff-wide kickoff with each practice. Scheduling that was a challenge for busy private practices, as well as for the community health centers. Regular contact occurred between the coaches with timetables and deliverables that were there for particular elements and standards that had to be met.

Our medical council met once a month. The council included the physician and non-physician leadership of each practice. We highlighted a different standard at each meeting, shared best practices and came to an agreement on the three conditions that one needs to identify for NCQA medical home recognition. There was agreement across the practices that diabetes was an important condition in our area and there was also agreement on adopting practice guidelines, which had already been worked on at the statewide level, so that was a non-controversial area to be able to tackle. We also had two full-day workshops called learning collaboratives, and continue to have these every six months. For these workshops, outside speakers of national prominence came to talk about the medical home and some of the changes that needed to be done.

With all those areas of success, we had no difficulty agreeing on a clinically important condition and on defining a few more to pick from. Agreement on practice guidelines again came easily because of work that had already occurred. Most of the practices found that the standards that required documentation of an EHR functionality, while challenging to document on a piece of paper, were already present and didn’t require much radical change in their practice. These are the low hanging fruit, and showing some of this early on started to build the spirit of cooperation among the providers.

Excerpted from Guide to Physician Performance-Based Reimbursement: Payoffs from Incentives, Data Sharing and Clinical Integration.

3 2014 Trends for Health Plans

January 21st, 2014 by Jessica Fornarotto

Influencing primary care, aggregating and mining data, and embracing bundled or episode-based payments are three trends that will influence health plans in 2014, predicts Catherine Sreckovich, managing director in the healthcare practice at Navigant Consulting.

HIN interviewed Sreckovich on these trends prior to her presentation during HIN's tenth annual webinar on Healthcare Trends & Forecasts in 2014: A Strategic Planning Session.

HIN: Where will data analytics take health plans in the coming year, and how will this shape population health management offerings?

(Catherine Sreckovich): We're certainly hearing a lot about big data, and it will be an integral approach to merging this practice's or population's health, the ability to aggregate and mine data is going to be an essential capability for health plans for their predictive models. And the outputs of these models are going to enable the health plans to identify and stratify their members or population health. Member and patient demographics can also inform consumer engagement strategies to support population health. And the analytics are going to inform the effectiveness of different care management interventions and consumer engagement strategies.

HIN: Health plan case managers embedded alongside providers has become almost a de facto model. How will payors influence primary care delivery in the year to come?

(Catherine Sreckovich): There is a number of approaches evolving right now and that will continue to evolve as payors attempt to influence primary care delivery. One is the use of patient-centered medical homes (PCMHs) and other integrated models to expand the payor's role as the primary care case manager.

In addition to paying primary care providers to hire case managers and care coordinators, payors are pushing for shared savings arrangements with these primary care providers, such as within an accountable care organization (ACO), and to push them to manage the care for those with chronic conditions.

We're also seeing payors paying for primary care physicians to become certified PCMHs and to implement electronic health records (EHRs), either by paying directly for the certification of the technology or by adding bonus payments to their FFS rates.

Payors are also paying for incentives for primary care physicians to offer wellness programs such as smoking cessation or weight loss programs and are trying very hard to influence where and to whom primary care physicians refer their patients by giving them information about the cost and quality of other provider types, such as specialists and hospitals.

And we will continue to see that payors will target the larger primary care physician practices with whom they have a critical mass of members to achieve enough savings to offset the added costs of incentives, bonuses and shared savings arrangements. As a result, we expect that some of the smaller primary care practices will likely not receive the same level of support and push from payors.

In another example, we see payors increasingly partnering with non-traditional providers, such as retail-based clinics and community health centers to offer easily accessible primary care at lower costs. And this will certainly be an opportunity to address some of the physician supply shortages that we anticipate seeing in the next year or so as more and more people have access to healthcare insurance and coverage.

Finally, another approach payors are using is to offer members access to virtual doctor visits via webcam, for example, and other telemedicine approaches that are giving individuals access to these primary care providers to increase access to convenient and low cost primary care for their patients.

HIN: CMS and top-performing Pioneer ACOs are heavily invested in bundled or episode-based payments. Will more private payors embrace this reimbursement method as well?

(Catherine Sreckovich): Definitely. The bundled or episodic-based payment approaches are here to stay. We’re starting to see this take off in a number of states. For example, there are state innovation grants that CMS has provided to states like Arkansas, Ohio, Delaware and others looking for opportunities to implement multi-payor bundled payment initiatives. Although these are not necessarily the traditional ACO model, they built off of that ACO model.

We also see that the large health plans in various states are starting to build and develop ACOs. Key to these are the shared savings arrangements that they’re implementing with these payment approaches. So whether they’re bundled or episodic-based payments or whether they look more like a traditional ACO, if there is such a thing, we’re starting to see takeoffs on those kinds of models as payors and health plans become more creative in the development of their alternatives.

Excerpted from: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry

One-Minute Health Metrics Video: Welcome to the Medical Home Neighborhood

December 6th, 2013 by Jackie Lyons

There are more than 6,037 patient-centered medical home (PCMH) sites in the United States, according to the NCQA. To further reduce fragmented care, many PCMHs are expanding to house the entire care continuum — a phenomenon known as the Medical Neighborhood.

Medical home neighbors include specialists along with primary care clinicians to better coordinate care. This One-Minute Metrics video shows the members of the medical neighborhood, signs of a desirable medical neighborhood, good practices that make good neighbors and more.

Click here for other medical home resources.

5 Attributes of Medical Home Neighborhoods, Where Practitioners Unite for Patient Care

December 5th, 2013 by Cheryl Miller

"The healthcare world is changing in ways that many of us have never seen in our lifetime with the possible exception of Medicare," says Dr. Terry McGeeney, director of BDC Advisors, a veteran of the healthcare system for 30 years.

It has moved away from system fragmentation, patient disenfranchisement, technophobia and fee-for-service (FFS) to system coordination, patient-centeredness, tech savviness and fee-for-value reimbursement, where bundled payments and accountable care are the reality, Dr. McGeeney says.

Ultimately, the patient-centered medical neighborhood (PCMN), or network of physicians collaborating and coordinating care per the patient-centered medical home (PCMH) model, will be a partnership among practitioners, patients and their families that ensures and respects the decisions of the patients, says Dr. McGeeney during Medical Home Neighborhoods: Uplinking Specialists To Create Integrated Systems of Care, a November 20th webinar now available for replay. Dr. McGeeney examined the trend toward medical neighborhoods and effective strategies for building out the neighborhood.

Bridging the gap between physician and provider-speak and hospital-speak, and identifying and engaging specialists in the medical neighborhood are key, Dr. McGeeney continues. Transitioning a clinically integrated entity to a high-functioning medical neighborhood is a real opportunity and challenge.

What are the key attributes of a highly functioning medical neighborhood?

  • A clear agreement on a delineation of roles of the neighbors in the system. Many successful neighborhoods are establishing letters of agreement or understanding on who is going to do what.
  • Sharing clinical information needed for effective decision-making, reducing duplication and waste in the system, as supported by appropriate health information technology (IT).
  • Continuity of medical care when patients transition between settings, particularly important in the post-acute space, and the move toward risk and episodic bundled payments. The transition from clinic to the emergency room (ER) is also critical.
  • Focusing on patients’ preferences, whether it’s to the primary care clinic or through a dedicated care coordinator, with the PCMH playing a key role. Strong community linkages, including both clinical and non-clinical services, including pharmacy, behavioral health, etc.

The top ways for practices to build capacity, Dr. McGeeney says, is to do a workflow analysis, and add capacity when appropriate, ensuring all are empowered.

As with all new healthcare models, there will be challenges, says Dr. McGeeney, among them PCP buy-in, leadership; communication at multiple levels; unaligned incentives, technology updates, and a difficult transformation.

And perhaps the biggest risk to the PCMH and PCMN model is the lack of patient engagement needed to leverage patient choice, Dr. McGeeney adds.

Choosing the ideal specialists is a good way to start — specialists that possess good communication skills, strong reputations and high value.

But as with any neighborhood, the whole is often greater than the sum of its parts, and assuring specialists that this new model will result in improved quality, cost reductions, the reduction of duplicated, unnecessary work and a better life/work balance is key.

And not everyone will be invited into the neighborhood, Dr. McGeeney cautions: there will be winners and losers. “The reality is there’s a number of hospital beds in this country to contract. Some providers may be left out of networks and thereby left out of the potential to share in savings. Proper positioning in this new environment is critical.”

HINfographic: The Medical Home Neighborhood

November 18th, 2013 by Jackie Lyons

There are more than 6,037 PCMH sites in the United States, according to the NCQA. To further reduce fragmented care, many PCMHs are expanding to house the entire care continuum – a phenomenon known as the Medical Neighborhood.

Medical home neighbors include specialists along with primary care clinicians to better coordinate care, according to a new infographic from the Healthcare Intelligence Network. This HINfographic also includes successful tactics for medical home 'neighbors,' signs of a desirable medical neighborhood and medical home neighborhood advice and comments from actual healthcare organizations.

The Medical Home Neighborhood

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Information presented in this infographic was excerpted from: Medical Home Neighborhoods: Uplinking Specialists To Create Integrated Systems of Care. If you would like to learn more about medical home neighborhoods, this resource includes even more information, including how to help physicians understand the link between meaningful use, care coordination across the neighborhood, and detailed lessons learned in building medical neighborhoods.

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