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Patient Aligned Care Team - PowerPoint Presentation

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Patient Aligned Care Team - PPT Presentation

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

health care team medical care health medical team patient mental primary management face access disease centered provider principle risk

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Slide1

Patient Aligned Care TeamVHA’s implementation of the Patient Centered Medical Home

David A. Hunsinger, MD, MSHAMedical Director, Binghamton VA Outpatient Clinic

1Slide2

2

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

3Slide4

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

4Slide5

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

11Slide12

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

12Slide13

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

16Slide17

*

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

18

18Slide19

19

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?

19

19Slide20

20

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

22

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

24Slide25

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

26Slide27

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

29Slide30

ConclusionPrimary Care - Mental Health Integration is and will continue to be an essential component of the team delivery of effective care

30