PCMH Collaborative - Examples of Coordinated Care

ACHP's Patient-Centered Medical Home Collaborative

 

Coordinating Care, Improving Outcomes

 

What does care coordination look like? At Geisinger Health Plan of Danville, Pa., case managers will contact a local nursing home so that its administrators know to call a patient's primary care physician first before sending for an ambulance. They find out which community pharmacies do home deliveries or will pre-fill a prescription so that physicians will know where special-needs patients will be able to get their medications. And they help providers to think in terms of cost transparency and value so that, together with patients, they will use MRI facilities that produces the same results for half the costs of others.  

 

Care coordination of this kind is a hallmark of the Patient-Centered Medical Home model of care. It enlists teams of providers primary care physicians, specialists, nurse practitioners and ancillary service providers like nutritionists and behavioral health counselors to coordinate all preventive, chronic and acute services so that individual patients and entire communities maintain good health and avoid costly adverse health events.

 

 

In January 2008, members of the Alliance of Community Health Plans (ACHP) began a Patient-Centered Medical Home (PCMH) Collaborative to demonstrate improved outcomes and lower costs through the medical home model of care. The Collaborative plans have begun reporting to ACHP specific metrics that describe the quality and efficiency of care provided under the medical home model and how satisfied patients are with that care. Throughout 2009, Collaborative plans will continue to collect data, refine the measures to identify best practices and compare the results to baseline years to demonstrate improved performance.

 

By collecting and analyzing data from medical home practice sites, these health plans are able to give physicians extra support to fill the gaps in care that frequently occur once a patient leaves a physician's office. Armed with practice-generated records and data, a health plan case manager can identify patients with cardiovascular conditions, inquire about their health status over the phone and arrange for visits with the primary care provider or a nutritionist as needed before a costly stay at a hospital is required.  

 

This strong emphasis on coordination and results makes the ACHP Collaborative a unique endeavor. Early initiatives have focused on the process of becoming a medical home: Does a practice use patient-tracking and registry tools? Follow-up with patients who receive care in other settings? Adopt evidence-based guidelines? The ACHP Collaborative takes the next steps by measuring outcomes: Do medical home practices reduce hospital readmission rates among patients? Decrease the total cost of care? Are patients more satisfied with care?   

 

The metrics that the Collaborative plans use to gauge the quality of care delivered through the medical home are derived from four unique practice standards that participating plans have agreed to follow (in addition to standards developed by the National Committee for Quality Assurance). These standards were adopted by the Collaborative to encourage a greater degree of engagement from providers and health plans in implementing a medical home model of care.

 

By combining outcomes and coordination standards with the established NCQA process standards for becoming a medical home, Collaborative members expect to deliver improved population health, a better care experience and reduced per capita costs the Triple Aim of fixing the

ACHP Practice Standards: Examples of Ensuring Effective Care Coordination

 

What distinguishes the ACHP Collaborative? Here are four examples of how ACHP member plans are implementing the ACHP Collaborative Practice Standards in their medical home pilot program. These practice standards enable ACHP member plans to function as a critical service integrator and ensure that effective care coordination takes place.

ACHP Standard 1: Supporting Integration

 

UPMC Health Plan of Pittsburgh, Pa. understands that medical practices don't become medical homes overnight. It's an ongoing, collaborative process that calls for added resources and perspectives.

 

For example, one UPMC Health Plan-affiliated medical home practice (with a large patient population that faces financial barriers to accessing care) began a chronic care initiative that involved  free prescription samples to help fill gaps in care and supported treatment compliance for patients who struggled to cover normal copays.

 

However, this practice lacked a clear documentation process for distributed sample drugs and wasn't able to fully credit providers for addressing the gaps in care, says Jennifer Nolty, manager for provider network performance, UPMC Health Plan. In response, UPMC Health Plan worked with the practice to create a documentation process that kept track of distributed samples and helped providers keep up with their patient's medication intake. [W]e worked to map out the old process, identify the data elements that need to be collected in the patient chart and implement a new process flow, Nolty says.

 

UPMC Health Plan also provides clinical pharmacy support for its medical home pilot practices. Its clinical pharmacists review a practice's prescribing patterns and generate physician-specific reports on generic vs. brand name use, low-dose statin rates, anti-depression medications and other categories and comparisons. These reports can compare a physician's prescription patterns to network averages and identify prescribing outliers. These efforts show how a health plan can supply the perspective and resources that help physicians improve their care for patients and lower costs.

 

ACHP Standard 2: Value Measurement

 

For its medical home pilot program, Priority Health Plan of Grand Rapids, Mich. closely tracks patient outcomes for the 16 practice sites that are participating in its medical home program, which provides care for about 23,000 members. Each site receives a dashboard spreadsheet that tracks quality measures for diabetes care from month to month. Did diabetic patients receive an a1c blood test? Did they receive an eye exam? Nephropathy screening?  

 

Priority Health Plan representatives look for links between use of these quality measures and an overall decline in the cost of diabetes care, says Mindy Olivarez, senior administrator for patient-centered medical homes at Priority Health Plan. Specifically, Priority Health is aiming to achieve a significant reduction in emergency room service use as a result of medical home care. We're hoping to see a 2-5 percent reduction of ER and a 2-5 percent reduction in the total cost of diabetes care, she says.

 

A positive patient experience is also a critical component of Priority Health's medical home program. In January 2009, plan officials administered the Patient Assessment of Chronic Illness Care survey (developed by the McColl Institute for Health Care Innovation) to each of the participating sites.

 

This survey gauges 20 aspects of how patients and providers interact and the quality of that engagement. Did the physician discuss a treatment plan with you? Inquire about your health habits? Contact you after a visit? Recommend a dietitian or health coach?  

 

Recording and measuring the direct effects of the medical home on outcomes and patient experience points physicians and health plans towards best practices and improved quality of care.

 

ACHP Standard 3: High-Value Systems of Care

 

For Geisinger Health Plan (GHP) of Danville, Pa., 360 care means using claims and quality data reports from the 25 clinics in its patient-centered medical home pilot program to help physicians provide coordinated, high quality care in any settings patients find themselves in.

 

Part of 360 care means knowing more about the conditions of patients. In GHP's medical home pilot program, physicians know when their patients are admitted or readmitted to the hospitals. But they also go further: What were they admitted for? Heart failure? Did they have a diuretic protocol? Were they weighing themselves at home? Was there a weight gain pattern?

 

If we can get at it upstream, teach them to weigh themselves, adjust the diuretic if they see weight gain, we can prevent the big weight gain that leads to hospitalization. says Janet Tomcavage, vice president of health services at GHP, referring to weight gain that can exacerbate health risks for heart failure patients. 

 

GHP's case managers are responsible for contacting patients recently discharged from a hospital and arranging a follow-up visit with the primary care physician. Rather than working from a distant GHP office, the case managers for the PCMH practices work on site in the medical office and are fully integrated with the practices. This allows the case managers to introduce themselves to patients as someone who works directly with their doctor, Tomcavage says, and not with an insurance company. Care coordination of this kind ensures that patients receive the appropriate care at the right time and helps them maintain good health and avoid negative, costly health events. Since embedding these case managers, Geisinger has seen hospital readmissions drop significantly as one of the focus areas for these nurses is ensuring timely follow up for patients recently discharged from the hospital.

 

ACHP Standard 4: Practice Reimbursement

 

Independent Health Plan of Buffalo, N.Y. began its medical home pilot program in January 2009, involving 23 practice sites and 50,000 patient members. Prior to its medical home pilot, Independent paid primary care physicians primarily on a fee-for-service basis. However, this wasn't consistent with the medical home, says Dr. Tom Foels, medical director for Independent Health. We want to encourage primary care physicians to adopt medical home principles and not have a reimbursement model that works against that.  

 

For the first year of its pilot program, the total amount of reimbursement available for medical home practices is 30 percent greater than under the previous reimbursement model. Participating practices are eligible for pay-for-performance payments made at year's end, the normal fee-for-service amount and an additional 20 percent in a per member, per month capitation rate.

 

The additional payment pays for patient-centered services that are traditionally non-billable like care coordination and telephone consults. Independent divides the additional payment into monthly fixed amounts (two-thirds) and a year-end bonus for meeting performance and quality goals (one-third). For 2010, Independent will transition its model further away from fee-for-service and toward capitation. Its year-end payment for quality measures and capitation amount will increase to 85 percent of the pre-medical home reimbursement model. Fee-for-service will be reduced to 45 percent, maintaining the total average amount at 130 percent of the pre-medical home reimbursement model.  

 

This transition will help Independent Health encourage use of preventive services and immunizations, which will continue to be paid under a fee-for-service model. Payments for sick patient visits, however, will move to a prospective basis, which will allow providers more flexibility in managing recurrent visits. This reimbursement model is tailored for a network, HMO environment because it builds on the traditional, fee-for-service payment model and gradually introduces a more complicated capitation plan.

ACHP's  Collaborative Structure and Process Standards Standard 1: Supporting Integration through Health Care Teams   Plan provides additional support to providers (e.g. feedback on performance, in-office case management, etc.) to support medical home activities. Standard 2: Value Measurement Practice collects data on jointly developed indicators that measure its efficiency in delivering care. Practices demonstrate annual improvement in measures.   Standard 3: High-Value Systems of Care Practice acts as a primary coordinator of all care (including care received at inpatient and outpatient sites). The practice ensures that patients receive care at sites that have been selected based on the quality of care they provide. The practice actively reviews cases of patients who are receiving care at other sites and coordinates transitions in care.   Standard 4: Practice Reimbursement Plan provides reimbursement that supports medical home and aligns with the objectives.

 

What is a Patient-Centered Medical Home?   The Patient-Centered Medical Home (PCMH) is a health care model that facilitates partnerships between individual patients and families and their personal physicians. The PCMH model of care is based on the premise that the best health care has a strong primary care foundation and clear incentives for quality and efficiency. In a PCMH, care is managed across all elements of the patient's community to ensure patients receive culturally and linguistically appropriate care when and where they need and want it.    At the core of the PCMH model is the concept of care management. The American Academy of Family Physicians defines care management as a health care management concept encompassing population management, care coordination and health information technologies such as electronic medical records. Population management leverages medical expertise to address health-related issues for an entire community rather than a single patient at a time.     Care coordination ranges from medical practitioners helping patients navigating the health care system to primary care physicians organizing all aspects of a patient's preventive, acute and chronic needs.   Another defining attribute of the PCMH is the strengthening of the patient's personal, long-term relationship with a primary care physician. In a successful PCMH model, the primary care physician assumes overall responsibility for coordinating care among different heath service providers and settings while focusing on the best interests and personal preferences of the patient. A 2006 Commonwealth Fund Health Care Quality Survey found that patients who have a primary care physician incur fewer health care expenditures. In addition, patients tend to have lower mortality rates due to heart disease, cancer and stroke and lower rates of hospitalizations for ambulatory care sensitive diagnoses.     Finally, electronic medical records provide a means of communication for health care practitioners. Health information technology in the PCMH model increases efficiency by making clinical practice guidelines, disease and population-based registries and referrals readily available to all practitioners.

 

 

 

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