Download Patient-Centered Medical Home: A Multidisciplinary Perspective

Patient-Centered Medical Home:
A Multidisciplinary Perspective
MARANDA HERRING, PHARMD, BCACP
TARA BRUNER, MHS, PA-C
1
Conflict of Interest
• Speakers have nothing to disclose
2
Objectives
1. Discuss the PCMH model and key players in the
successful implementation of interdisciplinary
and integrated medical care.
2. Describe the goals of PCMH and list strategies for
achieving these goals.
3. Review the history and evolution of PCMH metrics
and standards.
3
History of PCMH
2008
1967
NCQA
developed
formal
recognition
of PCMH
2001
“Medical
Home”
introduced
by AAP
“Crossing the
Quality Chasm” was
published
1978
2007
International
Conference on
Primary Health Care
identified goals for
primary care
Joint Principles
of the PatientCentered
Medical Home
was published
HTTPS://WWW.PCPCC.ORG/CONTENT/HISTORY-0
HTTPS://WWW.AAPA.ORG/THREECOLUMNLANDING.ASPX?ID=1702
2010
ACA
offers
provisions
for PCMH
4
Health Care Spending as a Percentage of GDP,
1980-2013
HTTP://WWW.COMMONWEALTHFUND.ORG/PUBLICATIONS/ISSUE-BRIEFS/2015/OCT/US-HEALTH-CARE-FROM-A-GLOBAL-PERSPECTIVE
5
Health Care Transformation
The Affordable Care Act (ACA) of 2010 was designed to:
◦Increase the number of insured Americans
◦Improve access to quality healthcare
◦Decrease healthcare spending
HTTP://OBAMACAREFACTS.COM/AFFORDABLECAREACT-SUMMARY/
6
HTTP://WWW.AAFP.ORG/NEWS/PRACTICE-PROFESSIONAL-ISSUES/20150303AAMCWKFORCE.HTML
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Health Care Transformation
o One provision under the ACA was the establishment of the Center for
Medicare and Medicaid Innovation (Innovation Center).
o The Innovation Center was tasked with designing an innovative
healthcare model that would improve quality and access to care while
decreasing the overall cost of care.
o One method the Innovation Center implemented with the State
Innovation Models (SIM) Initiative.
o The SIM Initiative provides federal grants to states to design and test
innovative, state-based multi-payer health care delivery and payment
systems.
HTTP://OBAMACAREFACTS.COM/AFFORDABLECAREACT-SUMMARY/
HTTP://KFF.ORG/MEDICAID/FACT-SHEET/THE-STATE-INNOVATION-MODELS-SIM-PROGRAM-AN-OVERVIEW/
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Health Care Transformation
o In 2011, public payer—Arkansas Medicaid—and private
payers—Qualchoice and Arkansas Blue Cross and Blue Shield—
formed the Arkansas Payment Improvement Initiative (APII)
o Together, over one year, they developed an incentivized health
care payment model that would shift to a higher-quality and
more cost-efficient system of care
o In 2013, Arkansas was awarded $42 million in federal grants to
pilot the program
HTTP://KFF.ORG/MEDICAID/FACT-SHEET/THE-STATE-INNOVATION-MODELS-SIM-PROGRAM-AN-OVERVIEW/
9
Arkansas Payment
Improvement Initiative (APII)
The Arkansas Payment Improvement Initiative (APII) aims to
shift the health care system from encounter-based service
to care coordination by incorporating two complementary
strategies statewide:
1. Episode-based payment for select disease states
2. Population-based advanced primary care through patientcentered medical homes (PCMHs)
HTTP://WWW.PAYMENTINITIATIVE.ORG/MEDICALHOMES/PAGES/DEFAULT.ASPX
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Episodes of Care
o A collection of medical conditions and procedures identified by APII as
“opportunities” for population management and cost savings
o ”Episodes” are characterized by a diagnosis code (ICD-10) and are time based
o Providers receive a fee-for-service and either share in cost (cost sharing) or in
saving (shared savings) depending upon cost and quality of care provided
Medical
Procedural/Surgical
Behavioral Health
Asthma/COPD
Cholecystectomy
Perinatal
ADHD
CHF
Colonoscopy
Tonsillectomy
ODD
URI
CABG
Total Joint Replacement
HTTP://WWW.PAYMENTINITIATIVE.ORG/MEDICALHOMES/PAGES/DEFAULT.ASPX
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Episodes of Care
HTTP://WWW.NASHP.ORG/CONDUCTING-THE-ORCHESTRA-OF-MULTI-PAYER-PAYMENT-REFORM-ACHIEVING-HARMONY-IN-ARKANSAS-AND-VERMONT/
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PCMH
“In a PCMH, clinicians work together to
provide care that is comprehensive, ongoing
and coordinated. The clinical team provides
primary, acute and preventive medical care.
The team also integrates specialty referrals
and other services from the health system
and community.”
https://www.aapa.org/twocolumnmain.aspx?id=291
13
PCMH
Hospita
l
Nurse
Pharmacist
M
e
n
t
a
l
H
e
a
lt
h
Pharmacist
Community Resources
PCP &
Patient
Spe
ciali
st
Mental Health
Dietition
C
o
m
m
u
ni
t
y
R
e
s
o
u
r
c
e
s
Dietitian
PCP & Patient
Specialist
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PatientCentered
PCMH
The Agency for Healthcare
Research and Quality (AHRQ)
has identified a PCMH as a
model encompassing the
following characteristics and
attributes:
Coordinated
Safe
High
Quality
Accessible
Comprehensive
HIGGINS T.C., SCHOTTENFELD L., & CROSSON J. (2015 PRIMARY CARE PRACTICE FACILITATION CURRICULUM (MODULE 25; AHRQ PUBLICATION NO. 15-0060-EF). ROCKVILLE, MD: AGENCY
FOR HEALTHCARE RESEARCH AND QUALITY
15
Goals of PCMH
o Achieve the “Triple Aim”
HTTP://WWW.IHI.ORG/ENGAGE/INITIATIVES/TRIPLEAIM/PAGES/DEFAULT.ASPX
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PCMH Requirements & Incentives (State)
Arkansas Payment Improvement Initiative (APII)
oCare Coordination
o Per Member Per Month Payments
o Implement, perform, and attest to “practice support activities”
o Shared Savings
o Quality metrics
o Action based vs. Outcomes based
=HTTP://WWW.PAYMENTINITIATIVE.ORG/MEDICALHOMES/PAGES/DEFAULT.ASPX
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APPI PCMH Activities and Metrics
PRACTICE SUPPORT
Activities
◦ Identify top 10% (most expensive)
◦ Assess practice operations
◦ Develop and implement strategies for care
coordination
Metrics
◦ Care plan containing:
◦ Problem list
◦ Contributions from health care team
and beneficiary
◦ Instructions for follow-up
◦ Assessment of progress to date
HTTP://WWW.PAYMENTINITIATIVE.ORG/MEDICALHOMES/PAGES/DEFAULT.ASPX
QUALITY METRICS
o EPSDT/WCC
o Diabetes HgA1c testing
o Appropriate asthma medications
o CHF patients on B-blocker
o Women over 50 with mammograms
o 30 day ADHD follow-up
o TSH testing for those on thyroid medications
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PCMH Requirements & Incentives (National)
National Committee for Quality Assurance (NCQA)
o Practice Recognition Program
o “Gold Standard” PCMH model
o Required up-front cost
oTraining and assistance for practice
transformation
o Level of recognition increases per member
per month payments
o Recognition achieved by meeting
predetermined standards
HTTP://WWW.NCQA.ORG/PROGRAMS/RECOGNITION/PRACTICES/PATIENT-CENTERED-MEDICAL-HOME-PCMH
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NCQA Recognition Standards
1. Enhance Access and Continuity
 Patient-centered appointment access
 24/7 access to clinical advice
 Patient Portal
 Meaningful Use
2. Team-Based Care
 Organization assigns team roles
 Scheduled team meetings
4. Plan and Manage Care

Care planning and self-care support
5. Track and Coordinate Care

Referral tracking and follow-up
6. Measure and Improve Performance

Continuous quality improvement
3. Population Health Management
 Use of data for population management

Informatics
HTTP://WWW.NCQA.ORG/PROGRAMS/RECOGNITION/PRACTICES/PATIENT-CENTERED-MEDICAL-HOME-PCMH
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Building a High-Functioning Health Care Team
CHARACTERISTICS OF EFFECTIVE TEAMS
CHARACTERISTICS OF EFFECTIVE TEAM MEMBERS
o Shared goals and purposeful collaboration
o Honesty
o Diverse knowledge and experience
o Discipline
o Clear roles
o Appropriate delegation
o Creativity
o Mutual trust
o Humility
o Effective communication and coordination
o Curiosity
o Measurable processes and outcomes
o Cost effective
o Improved health outcomes
HTTPS://WWW.NATIONALAHEC.ORG/PDFS/VSRT-TEAM-BASED-CARE-PRINCIPLES-VALUES.PDF
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Team Members
Responsibilities
Physician*
Physician Assistant*
Nurse Practitioner*
o
o
o
o
o
o
o
Nurse
o Triage patients
o Communicate results of labs, imaging, diagnostic tests, and procedure results
to patient
o Administer immunizations
o Detailed documentation
Pharmacist
o
o
o
o
o
o
o
Patient
o Attend all appointments (referrals & follow-up)
o Medication and device adherence
Diagnosis of disease
Prescribing medications and devices
Referral to specialists
Ordering labs, imaging, diagnostic tests, and/or procedures
Detailed documentation
Disease education
Develop, monitor, and modify treatment goals
Medication histories and reconciliation
Medication therapy assessment
Assessment of medication adherence
Prior authorizations and medication assistance
Disease, medication, and device education
Administer immunizations
Detailed documentation
22
Examples in Practice:
Making Pharmacists Part of the Team
23
History, Adherence, & Medication
Reconciliation
o Collaboration
between
community and clinic pharmacists
o Target high priority beneficiaries
o Identify and implement
opportunities for improved
adherence
o Identify duplicate therapy and
significant drug interactions
o Enhanced chart documentation
24
History, Adherence, & Medication
Reconciliation Service
25
Prior Authorization & Therapeutic
Substitution Services
o Collaboration between providers
and pharmacists
o Prior authorization
o Ensure timely access to medication
o Improves patient experience
o Improve outcomes
o Prospective therapeutic substitution
o Avoid delay in medication therapy
o Decrease cost of care
26
Diabetes Self-Management Education
o Population management
oHigh risk population
o Over 29 million Americans have diabetes
o Of these, nearly 28% have yet to be diagnosed
o Estimated cost to healthcare system in 2012: $245 billion
o Improved clinical outcomes
o Opportunities for family involvement
o Individual or group visits
oMedicare Part B covers up to 10 hours during initial year of diagnosis and
o CPT Codes:
HTTPS://WWW.PCPCC.ORG/RESOURCE/MEASURING-IMPLEMENTATION-AND-EFFECTS-COORDINATED-CARE-MODEL-FEATURING-DIABETES-SELF
HTTP://WWW.AADEMEETING.ORG/DSME-PROGRAM-STRENGTHENS-PATIENT-CENTERED-MEDICAL-HOME/
HTTP://WWW.DIABETES.ORG/DIABETES-BASICS/STATISTICS/?REFERRER=HTTPS://WWW.GOOGLE.COM/
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Smoking Cessation Counseling
o Population
management
oHigh risk population
o Over 16 million Americans have a disease caused from smoking
o Smoking is the leading cause of preventable death worldwide
o Cigarette smoking is responsible for over 480,000 deaths each year in the US
o Numerous studies have shown that smoking cessation counseling along with
pharmacotherapy improves a patient’s change of quitting and remaining smoke-free months later
o Reimbursement opportunities
oMedicare Part B covers up to 8 face-to-face visits for smoking cessation
counseling in 12 months
o CPT Codes 99406 and 99407
HTTP://WWW.CDC.GOV/TOBACCO/DATA_STATISTICS/FACT_SHEETS/FAST_FACTS/
HTTPS://WWW.MEDICARE.GOV/COVERAGE/SMOKING-AND-TOBACCO-USE-CESSATION.HTML
HTTPS://WWW.CDC.GOV/MMWR/PREVIEW/MMWRHTML/MM6044A2.HTM
HTTP://WWW.COCHRANE.ORG/CD008286/TOBACCO_DOES-COMBINATION-STOP-SMOKINGHTTPS://WWW.CMS.GOV/OUTREACH-AND-EDUCATION/MEDICARE-LEARNING-NETWORK-MLN/MLNMATTERSARTICLES/DOWNLOADS/MM7133.PDF]MEDICATION-AND-BEHAVIOURAL-SUPPORT-HELP-SMOKERS-STOP
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Chronic Disease-State Management
Common Pharmacist-Managed Chronic Diseases
Hypertension
Hyperlipidemia
Diabetes
Osteoporosis
Asthma/COPD
o Population management, improved outcomes
o Quality metrics
oMedicare Part B benefit
o”Incident to Physician” billing
o CPT Code 99211
o Only available in hospital or physician-based clinics
HTTP://WWW.AAFP.ORG/FPM/2004/0600/P32.HTML
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Traditional Clinical Pharmacy Services
1. Immunization Services
•
•
Covered under Medicare Part B (clinic) and Medicare Part D (community)
Every member of the healthcare team has a role in vaccine advocacy and patient
education
2. Anticoagulation Services
•
•
Covered under Medicare Part B
Studies suggest a cost savings of over $168,000 per 100 patients annually in
pharmacist-led anticoagulation clinics
Collaborative practice agreement must include written protocol
Non-vitamin K antagonist oral anticoagulants now preferred over warfarin
•
•
•
INR testing and frequent follow-up not required.
HTTP://BOK.AHIMA.ORG/PDFVIEW?OID=106618
HTTP://WWW.PHARMACYTIMES.COM/CONTRIBUTOR/BETH-LOFGREN-PHARMDBCPS/2015/01/HOW-TO-CONVERT-BETWEEN-ANTICOAGULANTS
HTTP://WWW.ACC.ORG/LATEST-IN-CARDIOLOGY/TEN-POINTS-TOREMEMBER/2016/03/02/15/45/ANTITHROMBOTIC-THERAPY-FOR-VTE-DISEASE
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Medication Therapy Management (MTM)
o Pharmacists
conduct comprehensive medication reviews and
identify and solve drug related problems
oMTM’s Roll in PCMH
oPopulation management (targets patients with multiple disease states and multiple
medications)
oIdentification and resolution of “drug-related problems” to improve health
outcomes and decrease cost of care long term
oCommunity pharmacists serve are the most accessible members of the PCMH
“team”
oOpportunity
o Improve patient outcomes
o Currently only about 11% of patients who are eligible for MTM under Medicare Part D are receiving
these services
HTTP://AVALERE.COM/EXPERTISE/MANAGED-CARE/INSIGHTS/FEW-MEDICARE-BENEFICIARIES-RECEIVE-COMPREHENSIVE-MEDICATION-MANAGEMENT-SERV
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Device Education
oImprove patient experience and optimize outcomes
oEpiPens®
oGlucometers
oInsulin Pens/Syringes
oInsulin Pumps
oInhalers and Spacers
oPeak Flow Meters
oDiastat ®
HTTP://WWW.ASHPINTERSECTIONS.ORG/2016/02/PRIMARY-CARE-CENTERS-LEVERAGE-PHARMACISTS-TO-EXPAND-PATIENT-CARE/
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Transitions of Care
o Population management, care coordination, improving access to care,
decrease cost of care (reduced readmission)
o Identify patients who have been hospitalized or have visited the ER
o Contact patient by phone within 2 days of discharge
o Educate and answer questions
o Schedule follow-up appointment with PCP within
7-14 days of discharge (Ins. specific)
o Medicare Part B benefit
o CPT Codes
o 99495
o 99496
HTTPS://WWW.ACPONLINE.ORG/PRACTICE-RESOURCES/BUSINESS-RESOURCES/CODING/GENERAL-CODING-RESOURCES/WHAT-PRACTICES-NEED-TO-KNOW-ABOUTTRANSITION-CARE-MANAGEMENT-CODES
33
Utilization of Technology in PCMH
o Electronic Medical Record
o Standardized documentation
o Template utilization
o Easily collect and analyze patient data
o Use in population management and quality improvement research
oPatient Portal
Access to patient information anytime, anywhere
o Communicate labs results
o Share discharge summaries
o
o Improves coordination of care and health outcomes
oSHARE
o Arkansas State Health Alliance for Records Exchange
o Secure, state-wide health information exchange
o Allows health professionals to exchange electronic information
o Improves coordination of care and health outcomes
HTTP://WWW.SHAREARKANSAS.COM/
34
High Priority Beneficiary Documentation
35
Care Plan
36
Research
o Continuous quality assurance and improvement
o Requirement for NCQA
oMedication Use Evaluation (MUE)
o Pushing prescribing to more cost effective, evidence based drug selection
37
Requirements for Pharmacists
o Scope of practice
o Collaborative practice agreements
o Policies, procedures, or protocols
o Standardized documentation
o IRB approval when applicable
38
Challenges
o Logistics
o Limited time and space
o Workflow management
o Lack of standardization in documentation/forms/requirements
o Collaborative practice agreement
o Scope of practice
o Communication
o Verbal
o Written
o Payment/Reimbursement
o Pharmacists not recognized as provider by Medicare Part B (except when immunizing)
o MTM services covered under Medicare Part D only
39
Reimbursement/Payment Opportunities:
o Supported by Per Member Per Month payments
o Direct billing for covered services
o Immunization
o Diabetes self-management education
o “Incident to” billing
o Use of CPT Modifier
HTTP://WWW.AAFP.ORG/FPM/2004/0600/P32.HTML
40
Reimbursement/Payment Opportunities:
“Incident-to” Billing
o The delegation, by a physician, of certain medical services or tasks to be
performed by a non-physician working under the supervision of the physician
o Clinics may negotiate contracts with private payers to ensure pharmacist
reimbursement for pharmacy services
o CPT Code 99211
o Level-I established patient encounter code
o “Office or other outpatient visit for the evaluation and management of an established
patient that may not require the presence of a physician.”
o Use for patient education, follow-up visits, and medication reviews
o Policies vary by payer
o Payments vary by payer
o Average unadjusted payment from Medicare for 99211 in 2004 was $21
HTTP://WWW.AAFP.ORG/FPM/2004/0600/P32.HTML
41
Reimbursement/Payment Opportunities:
Use of CPT Modifiers
o If a nurse or pharmacist sees a patient on the same day as a provider
at the request of the provider, a second CPT code must be applied
o To receive payment for both CPT codes, add a “modifier”
o CPT Modifier 25
o Used to identify a “significant, separately identifiable E/M service by same
physician on same day of procedure or other service”
o Utilized for services “above and beyond” the usual E/M service
o Ex. Smoking cessation counseling or immunization
HTTP://WWW.AAFP.ORG/FPM/2004/0600/P32.HTML
HTTP://WWW.CODINGAHEAD.COM/2011/10/CPT-MODIFIER-25-USAGE-AND-REIMBURSEMENT.HTML
42
Cost, Quality, and Access Goals
Cost
◦ Reduce overall costs by reducing acute costs associated with risk and expense
◦ Increase preventive costs to reduce future risk and costs
Quality
◦ Doesn’t allow for patients to slip through the cracks
◦ Makes sure the “of course we do” things are actually getting done
◦ Have to stay up on EBM in order for risk reduction
Access
◦ Increase access to a “home”
◦ Increase access to round-the-clock care
◦ Increase access to preventive services
43
Clinic Team
Communication:
Our Experience
o Progress board
o ”Huddle” reports
o Team incentives
44
Stumbling Blocks: Our Experience
o Resources
o Sizable clinic
o Empowering the team
o EMR support
o Healthcare IT
45
Assessment: Our Experience
o Opened eyes to things we thought we were doing well
o Pick HPBs so that we can make the most impact
o Have an IT-Medical team that communicates needs well
o Build a good PCMH team
o Beta test processes—ONE RIGHT WAY!
o Track and audit
o Don’t ease up on the non-compliant (patients and employees)
o Get to autopilot
46
The Future in Arkansas
Medicaid & Other
Third Party Payers
PCMH
Medicaid
PCMH
Current
Medicare & Other
Third Party Payers
Future
CPC+
47
Summary
◦ PCMH is a team-based, patient and family-centered care
model—not just a location—that focuses on
comprehensive, coordinated care that improves the
quality of care for all patients while reducing overall
healthcare spending
◦ PCMH offers opportunities for nearly all clinic staff to
improve care coordination and patient care outcomes
◦ Continuous quality improvement research is important to
identify stumbling blocks, improve team dynamics and
processes, and increase revenue
48
Contact Information
◦MaRanda Herring, PharmD, BCACP
[email protected]
◦Tara Bruner, MHS, PA-C
[email protected]
49
References
50
Acknowledgements
o JP Wornock, MD
o Amanda Diles, MHS, PA-C
o Eric Booth
o PrimeCare Team
o Harding University College of Pharmacy
51
Question #1
The “Triple Aim” is a strategic group of principles created by the Institute for Healthcare
Improvement (IHI) to do all of the following EXCEPT:
A.
B.
C.
D.
Improve the patient’s experience
Improve population health
Reduce the cost of healthcare
Reduce medication errors
52
Question #2
The patient-centered medical home (PCMH) is a care-based delivery model where patient
treatment is _____________ through primary care physicians to ensure appropriate
communication with downstream providers and improved patient care.
A.
B.
C.
D.
Coordinated
Planned
Outsources
Filtered
53
Questions?
54