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Patient Centered Medical
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What it means for Duffy Health Center
Board Presentation
September 10th 2012
Patient Centered Medical Home
• The aim is increased access to quality
patient care
• It involves a team based approach to care
DEFINITION OF PCMH LEVEL 1
• 6 MUST-PASS ELEMENTS
• 1A
– Providing Same Day Appointments
– Providing timely clinical advice by telephone
– Documenting clinical advice in the medical
record
PCMH 2D Use Data for Population
Management
• Practice uses patient information, clinical
data and evidence based guidelines to
generate lists and proactively remind
patients and clinicians about
– At least 3 different preventive care services
– At least 3 different chronic care services
– Patients not recently seen by practice
– Specific medications.
PCMH 3C – Care Management
- Patient collaboration with individual care
plan including treatment goals
- Written plan of care/Clinical summary
- Assess and Address barriers when
treatment goals not met
- Identify patients/families who might
benefit from additional care management
- Follow up if missed appointments
PCMH 4A – Support Self Care
Process
- Provides educational resources to at
least 50% patients in the identified group
to assist in self management
- Develops and documents self
management plans
- Provides self management tools
- Documents self management abilities
- Counsels on adopting healthy behaviors
PCMH 5B – Referral Tracking and
Follow up
- Tracking referral status including timing
- Following up to obtain specialist’s report
- Providing electronic summary of care
record for >50% referrals
- Asking patients about self-referrals and
requesting reports
-Demonstrate capability of electronic
exchange of key clinical information
PCMH 6C- Implement Continuous
Quality Improvement
- Set goals and act to improve performance on 3
clinical quality and resource measures
- Set goals and act to improve performance on
at least 1 patient experience measure
-Set goals to address 1 identified disparity in
care or service for vulnerable populations
OTHER IDEAS BEHIND PCMH
• QUALITY IMPROVEMENT
• TEAM CREATION
• HUDDLE
• CARE MANAGEMENT – RN BILLING
• PREPARATION FOR NCQA LEVEL 2 AND 3
WHICH INVOLVES MORE CRITERIA
New Tasks that will be added as
part of PCMH
• Disease registry data entry, maintenance,
monitoring
• Increased patient outreach, phone contact
• Increased results reporting
• Time intensive patient education
• Group visits
• Motivational interviewing
New Tasks cont’d
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Self management follow up
Expanded hours
Open access
Increased patient phone, email access
More thorough documentation
Increased patient follow up
Increased communication with other
providers/specialists
New Tasks mean cross training
staff and elevating to top of license
care
• Examples
– Providers – develop medical care plan which lower
level staff can carry out and monitor
– RN uses care plan to assess and treat complex
patients, also educate and coach chronic patients e.g.
strep throat protocol, STD training protocol
– MA – maintain disease registry, basic admin tasks
– Front desk – keep data for open access scheduling,
follow up patients who don’t keep specialists
appointments
Suggestions for achieving New
Tasks
• INFRASTRUCTURE
• TIME
• STAFF – RN CARE MANAGER
PROPOSED TIMELINE
• September 13th – Follow up start of open
access – Medical/BH
• September 27th – BH open access, follow
up data from Medical, decide clinical
reminders
• October 11th – Team formation, challenges
with BH, decide with PIC input on which
groups high risk
PROPOSED TIMELINE CONT’D
• November 5th – Patient experience is one
of the measures, review current survey
and/or use developed survey
• December – data review, places where we
need improvement