VHAs implementation of the Patient Centered Medical Home David A Hunsinger MD MSHA Medical Director Binghamton VA Outpatient Clinic 1 2 Statement on the PCMH President Obama ID: 733413
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Patient Aligned Care TeamVHA’s implementation of the Patient Centered Medical Home
David A. Hunsinger, MD, MSHAMedical Director, Binghamton VA Outpatient Clinic
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Statement on the PCMH: President Obama
“I support the concept of a patient-centered medical home, and as part of my health care plan, I will encourage and provide appropriate payment for providers who implement the medical home model, including physician-directed, interdisciplinary teams, care management and care coordination programs, quality assurance mechanisms, and health IT systems which collectively will help to improve care.”President Barack ObamaSlide3
3Joint Principles of the
Patient-Centered Medical Home AAFP, AAP, ACP, AOA
Ongoing relationship with personal physicianPhysician directed medical practiceWhole person orientationEnhanced access to careCoordinated care across the health systemQuality and safetyPayment
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Principle 1Personal Physician (Provider)Every patient has a designated primary care provider.
Relationship is ongoing – continuous over timePatient choiceEach physician has a “Panel” of patients
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Principle 2Physician (Provider) DirectedProvide clinical direction
Shared-Decision makingTeam-based care, leading the teamFlattening the hierarchical structures
Equal Value, Different RolesChampioning principles of Medical HomeExample: Facilitating Care Coordination5Slide6
Principle 3Whole Person OrientationHealth as a focus, not just Health Care
Personal preferences of the patient drive care interventionsPatient self-management skills and educationCulturally relevant and sensitive
Shared goal setting with health care teamHealth literacy and numeracyFamily engaged in careMental Health and Primary Care Integration6Slide7
Principle 4 Enhanced Access to CareOpen Access principles (ACA)
Ready and timely access to non face-to-face careTelephone, Messaging, Secure e-mailWeb-based access to scheduling, information, records, labs
System Redesign7Slide8
Principle 5Coordinating Care Transitions within and without
Identifying and managing highest riskChronic Disease ManagementPopulation-based Health CarePredicative Modeling
Health Risk Assessment ToolsPatient/Disease Registries8Slide9
Principle 6Quality and SafetyClinical performance
Value = Quality/CostMedication reconciliationQuality and Safety are outcomesEffectively managing transitions
Team dynamic drives performanceEffective implementation of Medical HomeData driven, team-based, system redesignContinuous improvement9Slide10
Patient Centered Medical Home
Practice Redesign
Redesign team:
Roles
Tasks
Enhance:
Communication
Teamwork
Improve Processes:
Visit work
Non-visit work
Care Management & Coordination
Focus on high-risk pts:
Identify
Manage
Coordinate
Improve care for:
Prevention
Chronic disease
Improve transitions between PCMH and:
Inpatient
Specialty
Broader Team
Patient Centeredness: Mindset and Tools
Improvement: Systems Redesign, VA TAMMCS
Resources: Technology, Staff, Space, Community
Access
Offer same day appointments
Increase shared medical appointments
Increase non-appointment care Slide11
Primary Care – Mental Health IntegrationPC-MHI embodies the principles and focus of the Patient Centered Medical HomeWork on PC-MHI implementation facilitates PACT implementation
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12Principles
of the Patient-Centered Medical Home
Ongoing relationship with personal physicianPhysician directed medical practiceWhole person orientationEnhanced access to careCoordinated care across the health systemQuality and safetyPayment
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26% of Veterans who use VA health care are also being treated for a mental health diagnosis20% currently receive some or all of that care in a specialty Mental Health setting
Patients initially bring their mental health concerns to Primary Care
Screening for mental health problems takes place in primary care [Clinical Reminders]Referrals from Primary Care to Specialty Mental Health result in a high rate of no-showsMental Health and Primary CareA Natural Fit 13Slide14
Completely integrated within primary careOccupy the same space
Share the same resourcesParticipate in Team Meetings
Share responsibility for care of the whole patientTrue IntegrationFeatures of PC-MHI14Slide15
15Patient Aligned Care Team:
Objective
To improve patient satisfaction, clinical quality, safety and efficiencies by becoming a national leader in the delivery of primary care services through transformation to a medical home model of health care delivery.Slide16
Team RedesignThe Patient’s Primary Care Team:
Teamlet: assigned to ±1200 patients (1 panel)
Provider RN Care ManagerClinical AssociateLPNMedical AssistantHealth TechClerkTeam members
Clinical Pharmacy Specialist
± 3 panels
Medical Social Work
± 2 panels
Nutrition
± 5 panels
Mental Health
Case Managers
Trainees
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*
The Patient Aligned Care Team
Panel size adjusted
for
rooms and
staffing
For each parent facility
HPDP Program
Manager
Health
Behavior
Coordinator
My Health
e
Vet
Coordinator
Other Team Members
Pharmacy
Social Work
Nutrition
Case
Managers
Integrated
Behavioral
HealthSlide18
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Essential Transformational ElementsPatient Aligned Care Team
Delivering “health” in addition to “disease care”Veteran as a partner in the team Empowered with educationFocus on health promotion and disease preventionSelf-management skillsPatient Advisory BoardEfficient AccessVisits
Non face-to-face
Telephone
Secure messaging
Telemedicine
Others?
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Care coordinationOptimizes hand-offs between inpatient and outpatient care
Facilitates interface with specialty careSeamless co-management (Dual Care) with outside providersIncorporates tele-health, and HBPC servicesEmphasizes home care & rural healthEssential Transformational Elements Slide21
21Care Management/ Panel Management
Disease management and interface with specialty careChronic Care Model
Disease registriesIdentification of outliersTeam RN partnering closely with providersVeterans at high risk for adverse outcomes Pain managementReturning combat veteran care DepressionSubstance abuse
Essential Transformational ElementsSlide22
22Improve technological clinician support
Decision supportPredictive modelingCPRS user-friendliness
Information processingDevelop new measurement and evaluation toolsPatient SatisfactionStaff satisfactionProcesses of careManager and Provider Report Cards Continuity and comprehensiveness
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Essential Transformational ElementsSlide23
Whole Person Orientation
“ …you ought not to attempt to cure the eyes without the
head or the head without the body, so neither ought you to attemptto cure the body without the soul . . . for the part can never be wellunless the whole is well.”
PlatoSlide24
Mental Health is an Integral Part of Overall Health
Physical problems can be risk factors for mental health problemsMental health problems can be risk factors for physical health problemsPatient Centeredness means a holistic view of the Veteran, recognizing the interrelationships of all health problems and how they individually and interactively affect quality of life
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Proficiency in Motivational InterviewingParticipate in appropriate Team activitiesHuddles & Team MeetingsFrequent non-face-to-face phone contactKeep entire Teamlet in the loopCoordinate care with other VHA resources (i.e. CCHT, HBPC, ADHC, etc as appropriate)Educate Primary Care Team on MH issues
Expectations of the PC-MHI
Team25Slide26
Shared Medical AppointmentsPotential new role for the co-located Mental Health providerProvides patient-care in a group settingMental Health provider often assists with group management
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Shared Medical AppointmentsHave a component of education, but…
Alternative to the traditional face to face, 1:1 doctor:patient interaction in an office.
This doctor:patient interaction is in a group setting (“1:1 with onlookers”).Slide28
Shared Medical AppointmentsOne-on-one care with observers
15-20 patients in 90 – 120 min. Patients learn from staff and from each otherCommonly facilitated by a Behavioral Health providerAppeals to about ½ of those offered optionSlide29
ConclusionPatient Aligned Care Teams strive to provide patient-centered, whole person health care and seek to work with the Veteran to coordinate and manage all aspects of their care
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ConclusionPrimary Care - Mental Health Integration is and will continue to be an essential component of the team delivery of effective care
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