Harold Brown, MBA – Chief Executive Officer - PowerPoint Presentation

Harold Brown, MBA – Chief Executive Officer Tammy Smith – Care Coordinator & CHW Achieving PCMH Status Using CHWs

Today’s Agenda Who are WE and who are YOU?What is a Patient-Centered Medical Home (PCMH)?CHW Role in Achieving PCMH Status? Now What? – Preparing for PCMH Application

Sterling Health Solutions, Inc., is a Federally Qualified Health Center, located in beautiful Mount Sterling, Kentucky, the heart of East Central Kentucky’s Gateway Area. Mount Sterling is rich in history and culture, with many arts and family-oriented community events scheduled throughout the year. Mount Sterling is situated thirty minutes east of the larger city of Lexington, Kentucky, which is the regional seat of equine, college sports and popular entertainment. Also, Mount Sterling is within driving distances of Louisville, Kentucky, which is the home of the internationally acclaimed Kentucky Derby. For further information on Mount Sterling and surrounding area, please click on the following links: http://www.mtsterlingtourism.com http://www.montgomery.kyschools.us http://www.visitlex.com http://www.kentuckytourism.com Mount Sterling, Kentucky

OUR FOCUSES Improve the health of the patients in our service area Increase access to quality healthcare services Reduce healthcare costs OUR MISSION To improve the lives for all people in the communities we serve through improved health regardless of the ability to pay for the services.

3 Primary Care Clinic Sites STERLING HEALTH CARE Primary Care, Pediatrics, and Behavioral Health Services 209 North Maysville Street, Suite 200 Mount Sterling, KY 40353 BATH FAMILY HEALTH SERVICES Primary Care and Substance Abuse/Behavioral Health Services 44 Water Street Owingsville, KY 40360 STERLING WOMEN’S CARE Obstetrics and Gynecology 15 Sterling Avenue Mount Sterling, KY 40353

Montgomery County Intermediate School 1040 Maysville Road Mount Sterling, KY 40353 Camargo Elementary 4307 Camargo Road Mount Sterling, KY 40353 Mapleton Elementary 809 Indian Mound Drive Mount Sterling, KY 40353 Mt. Sterling Elementary 6601 Indian Mound Drive Mount Sterling, KY 40353 J.B. McNabb Middle School 3570 Indian Mound Drive Mount Sterling, KY 40353 Montgomery High School 724 Woodford Drive Mount Sterling, KY 40353 6 School Based Clinic Sites

What is a Patient-Centered Medical Home (PCMH)?

Patient-Centered Medical Home The medical home, also known as the patient-centered medical home ( PCMH ), is a team-based health care delivery model led by a health care provider that is intended to provide comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. a model of care that emphasizes care coordination and communication The model is intended to improve the quality and efficiency of care delivery.

Benefits of the PCMH Model Quality – Patient OutcomesFewer ER visitsFewer hospital admissions Lower mortality rates Better preventive service delivery Better chronic disease care Higher patient satisfaction

Benefits of the PCMH Model Efficiency – CostLower total costs of careShorter patient wait timesLess staff burnout/turnover Higher staff satisfaction/productivity

JACHO www.JointCommission.orgJoint Commission on the Accreditation of Healthcare Organizations AAAHC www.AAAHC.org The Accreditation Association for Ambulatory Health Care NCQA www.NCQA.org National Committee on Quality Assurance PCMH Accrediting Organizations

NCQA (PCMH Program) 501(c)(3) dedicated to improving health care qualityNCQA offers “recognition” programs for various aspects of clinical care: diabetes, cardiovascular disease, back pain One of the recognition programs is for PCMH 3 levels of accreditation: Level 1 (lowest), Level 2, and Level 3 (highest)

Scoring a Standard Each Element in a Standard is worth a certain number of points. To achieve the points, you must complete some (or all) of the factors in that element.Note: The actual details of scoring each element depends on that specific element and is NOT the same across the board.

Point Requirements Level of Recognition Points Required (2011) Level I 35-59 (6/6 must pass) Level 2 60-84 (6/6 must pass) Level 3 85-100 (6/6 must pass)

“Must Pass” Elements Some elements are “Must Pass”**To “Pass” one of these elements, you must receive a 50% score or higher**You must pass all 6/6 of the “Must Pass” elements to achieve any level of recognition.

NCQA Lingo each “standard” is composed of several “elements” each “element” is composed of several “factors”

PCMH (2011) Overview Enhance Access and Continuity Access During Office Hours Access After Hours Electronic Access Continuity (with provider) Medical Home Responsibilities Culturally/Linguistically Appropriate Services Practice Organization Identify/Manage Patient Populations Patient Information Clinical Data Comprehensive Health Assessment Use Data for Population Management Plan/Manage CareImplement Evidence-Based Guidelines Identify High-Risk PatientsManage Care Plan/Manage Care (continued) Manage MedicationsElectronic PrescribingProvide Self-Care and Community ResourcesA. Self-Care ProcessB. Referrals to Community ResourcesTrack/Coordinate CareTest Tracking and Follow-Up Referral Tracking and Follow-UpCoordinate with Facilities/Care Transitions Measure & Improve Performance Measures of PerformancePatient/Family Feedback Implements Continuous Quality Improvement Demonstrates Continuous Quality Improvement Report Performance Report Data Externally

CHW Role in Achieving PCMH

CHW Definition “ a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served” American Public Health Association 2009

CHW’s role in the care setting Community health workers provide seamless, continuous, coordinated, and patient-centered care in the community and clinical sector.

Other services provided by CHW Provide support to both patients and staffFilter incoming calls for providers, assess the patient’s need or concerns, staffing with the provider and returning a call with the resolution Connecting patients to resources in the community Coordinates care between our facility and other facilities Increases patient access to insurance coverage by helping patient’s sign up on the federal exchange Ultimately a CHW’s role in this setting is to close the care gaps for the patient’s they serve.

PCMH Planning / Steering Committee Team Includes:“PCMH Champion” who will help guide the practice through the quality transformation process “Communicator-In-Chief” who will serve as a point person for interactions with Community Care and other support staff “Lead Administrator” who will track progress, organize materials, complete the PMCH application (should have computer skills)

Lead Administrator & Chief Communicator - CEO PCMH Champion - CMO Clinical Support Staff Rep – DON Non-Clinical Support Staff Rep – CHW Expert Support - Consultant PCMH Planning Team / Steering Committee

PCMH (2011) Overview Enhance Access and Continuity Access During Office Hours Access After Hours Electronic Access Continuity (with provider) Medical Home Responsibilities Culturally/Linguistically Appropriate Services Practice Organization Identify/Manage Patient Populations Patient Information Clinical Data Comprehensive Health Assessment Use Data for Population Management Plan/Manage CareImplement Evidence-Based Guidelines Identify High-Risk PatientsManage Care Plan/Manage Care (continued) Manage MedicationsElectronic PrescribingProvide Self-Care and Community ResourcesA. Self-Care ProcessB. Referrals to Community ResourcesTrack/Coordinate CareTest Tracking and Follow-Up Referral Tracking and Follow-UpCoordinate with Facilities/Care Transitions Measure & Improve Performance Measures of PerformancePatient/Family Feedback Implements Continuous Quality Improvement Demonstrates Continuous Quality Improvement Report Performance Report Data Externally

Standard 1, Element B Factor 2Providing timely clinical advice Filters incoming calls for BH providers. Staffs the issue with the correct provider and places a return call with a resolution. Factor 4 Documenting clinical advice in the patient chart Records the interaction in the patient’s chart in the log notes.

Factor 1 Coordinating patient care across multiple settingsGets information about services the provider is referring the patient to and aids in arranging the service.Factor 7Gives uninsured patients information about obtaining coverage. Helps the patient’s sign up for coverage through the federal exchange or refers the patient to the appropriate agency. Standard 2, Element B

Factor 3 Provides interpretation or bilingual services to meet the language needs of its populationWe have a CHW staff that is bilingual and provides interpretation services for our Hispanic patients.Standard 2, Element C

Factor 6 Assisting patient’s/families/caregivers in self-managementHelping the patient/families/caregivers overcome whatever barriers they may be facing in achieving self-management of their mental or health conditions. Standard 2, Element D

Factors 1-5 Run reports and send notifications to patients that have care gaps such as chronic health conditions, immunizations or not been seen for an extended period of time.It is important to help our patients maintain and improve their health. By running reports that are targeted need specific we can send reminder letters to our patients about needed appointments, missing immunizations, preventative screenings and more. This goes a long way in helping close care gaps that can often prevent the patient from reaching or maintaining their goals. Standard 3, Element D

Factor 2 Provides educational material and resources to patients.Helping patients gain access to educational material and resources on a local, state and national level. Factor 6Maintains a current resource list on five topics or key community services.Continually updating resource lists for such things as housing, clothing, food, treatment centers and group meetings. Standard 4, Element E

Now What? – Preparing for PCMH Application

Application (free)Demographic information Interactive Survey Tool ($Charge – 80 for 2014 Recognition)Self-directed practice assessmentWhen ready, submit Interactive Survey Tool, Application, and final application fee Next Steps: Applying for PCMH Recognition

Next Steps Build Your PCMH Team:Identify a “PCMH Champion” who will help guide the practice through the quality transformation process Identify a “Communicator-In-Chief” who will serve as a point person for interactions with Community Care and other support staff Identify a “Lead Administrator” who will track progress, organize materials, complete the PMCH application (should have computer skills)

Next Steps Begin team discussions about where the manpower will come from. Practice transformation is valuable for your patients and your practice, but it takes time . Will you: Be able to reduce your patient load? Have to extend your hours? Need to work on the weekends? Need to shift duties/responsibilities?

Next Steps Peruse the NCQA “Standards and Guidelines” document or other Accrediting BodyThis is a long, but important document that is the backbone of the recognition process and familiarity with it is CRUCIAL to your success.

Sterling Health Solutions, Inc. 209 North Maysville Street, Suite 200Mt. Sterling, Kentucky 40353Phone: 859.404.7686Fax: 859.498.8160 www.sterlinghealthky.org