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Achieving PCMH Status
Using CHWs
Harold Brown, MBA – Chief Executive Officer
Tammy Smith – Care Coordinator & CHW
Today’s Agenda
• Who are WE and who are YOU?
• What is a Patient-Centered Medical Home (PCMH)?
• CHW Role in Achieving PCMH Status?
• Now What? – Preparing for PCMH Application
Sterling Health Solutions, Inc., is a Federally Qualified Health Center, located in beautiful Mount Sterling, Kentucky,
the heart of East Central Kentucky’s Gateway Area. Mount Sterling is rich in history and culture, with many arts and
family-oriented community events scheduled throughout the year. Mount Sterling is situated thirty minutes east of
the larger city of Lexington, Kentucky, which is the regional seat of equine, college sports and popular
entertainment. Also, Mount Sterling is within driving distances of Louisville, Kentucky, which is the home of the
internationally acclaimed Kentucky Derby.
For further information on Mount Sterling and surrounding area, please click on the following links:
http://www.mtsterlingtourism.com
http://www.montgomery.kyschools.us
http://www.visitlex.com
http://www.kentuckytourism.com
Mount Sterling, Kentucky
OUR MISSION
To improve the lives for all people in the communities we
serve through improved health regardless of the ability to pay
for the services.
OUR FOCUSES
• Improve the health of the patients in our service area
• Increase access to quality healthcare services
• Reduce healthcare costs
3 Primary Care Clinic Sites
STERLING HEALTH CARE
Primary Care, Pediatrics, and Behavioral Health Services
209 North Maysville Street, Suite 200
Mount Sterling, KY 40353
STERLING WOMEN’S CARE
Obstetrics and Gynecology
15 Sterling Avenue
Mount Sterling, KY 40353
BATH FAMILY HEALTH SERVICES
Primary Care and Substance Abuse/Behavioral Health Services
44 Water Street
Owingsville, KY 40360
6 School Based Clinic Sites
Montgomery High School
724 Woodford Drive
Mount Sterling, KY 40353
J.B. McNabb Middle School
3570 Indian Mound Drive
Mount Sterling, KY 40353
Mt. Sterling Elementary
6601 Indian Mound Drive
Mount Sterling, KY 40353
Mapleton Elementary
809 Indian Mound Drive
Mount Sterling, KY 40353
Camargo Elementary
4307 Camargo Road
Mount Sterling, KY 40353
Montgomery County Intermediate School
1040 Maysville Road
Mount Sterling, KY 40353
What is a Patient-Centered Medical Home (PCMH)?
Patient-Centered Medical Home
• The medical home, also known as the patientcentered medical home (PCMH), is a team-based
health care delivery model led by a health care
provider that is intended to provide comprehensive
and continuous medical care to patients with the
goal of obtaining maximized health outcomes.
• a model of care that emphasizes care coordination
and communication
• The model is intended to improve the quality and
efficiency of care delivery.
Benefits of the PCMH Model
Quality – Patient Outcomes
• Fewer ER visits
• Fewer hospital admissions
• Lower mortality rates
• Better preventive service delivery
• Better chronic disease care
• Higher patient satisfaction
Benefits of the PCMH Model
Efficiency – Cost
• Lower total costs of care
• Shorter patient wait times
• Less staff burnout/turnover
• Higher staff satisfaction/productivity
PCMH Accrediting Organizations
 JACHO www.JointCommission.org
• Joint Commission on the Accreditation of Healthcare Organizations
 AAAHC www.AAAHC.org
• The Accreditation Association for Ambulatory Health Care
 NCQA www.NCQA.org
• National Committee on Quality Assurance
NCQA (PCMH Program)
• 501(c)(3) dedicated to improving health care quality
• NCQA offers “recognition” programs for various aspects of clinical care:
diabetes, cardiovascular disease, back pain
• One of the recognition programs is for PCMH
• 3 levels of accreditation: Level 1 (lowest), Level 2, and Level 3 (highest)
Scoring a Standard
• Each Element in a Standard is worth a certain number of points.
To achieve the points, you must complete some (or all) of the
factors in that element.
• Note: The actual details of scoring each element depends on that
specific element and is NOT the same across the board.
Point Requirements
Level of
Recognition
Points Required
(2011)
Level I
35-59 (6/6 must pass)
Level 2
60-84 (6/6 must pass)
Level 3
85-100 (6/6 must pass)
“Must Pass” Elements
• Some elements are “Must Pass”
• **To “Pass” one of these elements, you must
receive a 50% score or higher**
• You must pass all 6/6 of the “Must Pass” elements
to achieve any level of recognition.
NCQA Lingo
each “standard”
is composed of
several
“elements”
each
“element” is
composed of
several
“factors”
PCMH (2011) Overview
1.
Enhance Access and Continuity
A.
B.
C.
D.
E.
F.
G.
2.
Identify/Manage Patient Populations
A.
B.
C.
D.
3.
Access During Office Hours
Access After Hours
Electronic Access
Continuity (with provider)
Medical Home Responsibilities
Culturally/Linguistically Appropriate Services
Practice Organization
Patient Information
Clinical Data
Comprehensive Health Assessment
Use Data for Population Management
Plan/Manage Care
A. Implement Evidence-Based Guidelines
B. Identify High-Risk Patients
C. Manage Care
3.
Plan/Manage Care (continued)
D.
E.
4.
Manage Medications
Electronic Prescribing
Provide Self-Care and Community
Resources
A. Self-Care Process
B. Referrals to Community Resources
5.
Track/Coordinate Care
A.
B.
C.
6.
Test Tracking and Follow-Up
Referral Tracking and Follow-Up
Coordinate with Facilities/Care Transitions
Measure & Improve Performance
A.
B.
C.
D.
E.
F.
Measures of Performance
Patient/Family Feedback
Implements Continuous Quality
Improvement
Demonstrates Continuous Quality
Improvement
Report Performance
Report Data Externally
CHW Role in Achieving PCMH
CHW Definition
“ a frontline public health worker who is a trusted member of and/or
has an unusually close understanding of the community served”
American Public Health Association 2009
CHW’s role in the care setting
• Community health workers provide seamless,
continuous, coordinated, and patient-centered
care in the community and clinical sector.
Other services provided by CHW
• Provide support to both patients and staff
• Filter incoming calls for providers, assess the patient’s need or concerns,
staffing with the provider and returning a call with the resolution
• Connecting patients to resources in the community
• Coordinates care between our facility and other facilities
• Increases patient access to insurance coverage by helping patient’s sign up
on the federal exchange
• Ultimately a CHW’s role in this setting is to close the care gaps for the
patient’s they serve.
PCMH Planning / Steering Committee
• Team Includes:
• “PCMH Champion” who will help guide the practice through
the quality transformation process
• “Communicator-In-Chief” who will serve as a point person for
interactions with Community Care and other support staff
• “Lead Administrator” who will track progress, organize
materials, complete the PMCH application (should have
computer skills)
PCMH Planning Team / Steering Committee
•
•
•
•
•
Lead Administrator & Chief Communicator - CEO
PCMH Champion - CMO
Clinical Support Staff Rep – DON
Non-Clinical Support Staff Rep – CHW
Expert Support - Consultant
PCMH (2011) Overview
1.
Enhance Access and Continuity
A.
B.
C.
D.
E.
F.
G.
2.
Identify/Manage Patient Populations
A.
B.
C.
D.
3.
Access During Office Hours
Access After Hours
Electronic Access
Continuity (with provider)
Medical Home Responsibilities
Culturally/Linguistically Appropriate Services
Practice Organization
Patient Information
Clinical Data
Comprehensive Health Assessment
Use Data for Population Management
Plan/Manage Care
A. Implement Evidence-Based Guidelines
B. Identify High-Risk Patients
C. Manage Care
3.
Plan/Manage Care (continued)
D.
E.
4.
Manage Medications
Electronic Prescribing
Provide Self-Care and Community
Resources
A. Self-Care Process
B. Referrals to Community Resources
5.
Track/Coordinate Care
A.
B.
C.
6.
Test Tracking and Follow-Up
Referral Tracking and Follow-Up
Coordinate with Facilities/Care Transitions
Measure & Improve Performance
A.
B.
C.
D.
E.
F.
Measures of Performance
Patient/Family Feedback
Implements Continuous Quality
Improvement
Demonstrates Continuous Quality
Improvement
Report Performance
Report Data Externally
Standard 1, Element B
Factor 2
• Providing timely clinical advice
• Filters incoming calls for BH providers. Staffs the issue with the
correct provider and places a return call with a resolution.
Factor 4
• Documenting clinical advice in the patient chart
• Records the interaction in the patient’s chart in the log notes.
Standard 2, Element B
Factor 1
• Coordinating patient care across multiple settings
• Gets information about services the provider is referring the patient
to and aids in arranging the service.
Factor 7
• Gives uninsured patients information about obtaining coverage.
• Helps the patient’s sign up for coverage through the federal exchange
or refers the patient to the appropriate agency.
Standard 2, Element C
Factor 3
• Provides interpretation or bilingual services to meet the language
needs of its population
• We have a CHW staff that is bilingual and provides interpretation
services for our Hispanic patients.
Standard 2, Element D
Factor 6
• Assisting patient’s/families/caregivers in self-management
• Helping the patient/families/caregivers overcome whatever barriers
they may be facing in achieving self-management of their mental or
health conditions.
Standard 3, Element D
Factors 1-5
• Run reports and send notifications to patients that have care gaps
such as chronic health conditions, immunizations or not been seen
for an extended period of time.
• It is important to help our patients maintain and improve their health.
By running reports that are targeted need specific we can send
reminder letters to our patients about needed appointments, missing
immunizations, preventative screenings and more. This goes a long
way in helping close care gaps that can often prevent the patient from
reaching or maintaining their goals.
Standard 4, Element E
Factor 2
• Provides educational material and resources to patients.
• Helping patients gain access to educational material and resources on
a local, state and national level.
Factor 6
• Maintains a current resource list on five topics or key community
services.
• Continually updating resource lists for such things as housing,
clothing, food, treatment centers and group meetings.
Now What? – Preparing for PCMH Application
Next Steps: Applying for PCMH Recognition
• Application (free)
• Demographic information
• Interactive Survey Tool ($Charge – 80 for 2014 Recognition)
• Self-directed practice assessment
• When ready, submit Interactive Survey Tool, Application, and final
application fee
Next Steps
• Build Your PCMH Team:
• Identify a “PCMH Champion” who will help guide the practice
through the quality transformation process
• Identify a “Communicator-In-Chief” who will serve as a point
person for interactions with Community Care and other
support staff
• Identify a “Lead Administrator” who will track progress,
organize materials, complete the PMCH application (should
have computer skills)
Next Steps
• Begin team discussions about where the manpower
will come from. Practice transformation is valuable for
your patients and your practice, but it takes time.
• Will you:
• Be able to reduce your patient load?
• Have to extend your hours?
• Need to work on the weekends?
• Need to shift duties/responsibilities?
Next Steps
• Peruse the NCQA “Standards and Guidelines” document or other
Accrediting Body
• This is a long, but important document that is the backbone of the
recognition process and familiarity with it is CRUCIAL to your success.
Sterling Health Solutions, Inc.
209 North Maysville Street, Suite 200
Mt. Sterling, Kentucky 40353
Phone:
Fax:
859.404.7686
859.498.8160
www.sterlinghealthky.org