1.
How To Achieve a
Patient Centered Medical Home (PCMH)
Robbye Penrod CPC RMC RMA
Office Manager, MedPeds Medical Clinic, PA
Using
Nusrat Khan M.D. MBA FAAP
Medical Director, MedPeds Medical Clinic, PA

2.
MedPeds Medical Clinic, PA
Internal Medicine and Pediatrics
NCQA PCMH Level III Certified Facility
(by 2011 Standards )
1st Clinic in Texas to Achieve this Status under NCQA
2011 credentialing guidelines
• NCQA Recognition in Diabetes Care Management (DRP)
• NCQA Recognition in Heart/Stroke Care Management (HSRP)
• Bridges to Excellence Recognition in Medical Home Clinic
• Bridges to Excellence Recognition in Diabetes Care
• Bridges to Excellence Recognition in Preventative Cardiac Care
• Bridges to Excellence Recognition in Coronary Artery Disease
• Bridges to Excellence Recognition in Office Systems Management

3.
PCMH and Primary Care
Concept supported by the:
• American Academy of Family Physicians
• American College of Physicians
• American Academy of Pediatrics
• American Osteopathic Association
• American Association of Nurse Practitioners
• American Association of Physician Assistants
-Principles for the Patient Centered Medical Home;
this defines critical principles within the PCMH
model.

4.
What is PCMH?

5.
PCMH-The Concept
• Enhanced Patient Access - during and after office hours
• ‘Team-Based Care’ approach from the clinic team
• Improved delivery & tracking of preventive services
• Clinical excellence in chronic disease management
• Improved care at ‘Transition of Care’ points: Reduced utilization
of ER and hospitals
• Shared Decision Making: better quality and experience of care
• Long-term Patient & Provider Relationships
• High performing, cost effective, integrated care
delivery system

6.
Why bother with PCMH?
POINT
• Primary care reimbursement has not kept pace with the care burden
• For now there is no incentive payments for PCMH
COUNTER POINT
• Market forces & regulations within the system are forcing changes in
healthcare: the practice of medicine is transforming
• Consumers of healthcare are demanding better access to care, and
third party payers are transitioning to ‘pay for performance’
• There is a tsunami of change that is going to move us away from a
‘fee for service’ industry
• PCMH concepts are born out a need for such health care reform

7.
Standard 1
Enhance Access and Continuity
• Access during office hours
• Access after hours
• Electronic access
• Continuity
• Medical Home responsibilities
• Culturally and linguistically appropriate
• Practice Team Approach

8.
Access During Office Hours
• Provide Same-day appointments
• Provide timely clinical advice by
telephone during office hours
• Provide clinical advice by secure
electronic messages during office hours
• Documenting clinical advice in medical
record

9.
What We did
Improved Access to Care
• Offered timely care during & after hours
--innovative scheduling
• Adopted patient portals (Updox and A Charts)
• Electronic messaging
• Educated our patients to “Call Us First”
--so that we could direct their care

10.
Electronic Access Through

11.
Standard 2
Identify and Manage Patient Populations
• Patient Information- demographics
• Clinical Data-problem list, allergies, vital signs
• Comprehensive Health Assessment -
PMHx, SocHx, Advance Care Planning, Developmental
screenings, Depression screening

12.
What We did
• Use Amazing Charts to create reminders in the
system for age appropriate screenings
• Chronic Disease specific services:- example in
DM, CKD
• Use Amazing Charts to identify chronic disease
patients = high utilizers of care
• Use Amazing Charts to identify non-
compliance with follow-up

13.
Standard 3
Plan and Manage Care
• Implement Evidence Based guidelines
• Identify High Risk Patients
• Care Management
• Medication Management
• Use Electronic Prescribing

14.
Care Management
• Conducts pre-visit preparations
• Collaborates with patient to develop
individual care plan and gives patient written
plan of care
• Assesses barriers when the patient has not
met treatment goals
• Identifies patients who might benefit from
additional care/management support

15.
What We Did
Creating a healthcare delivery team in the office
• Diabetes Team Leader
• Preventative Care Team Leader
• Patient Care Coordinator
• Individual Care Plan

16.
Standard 4
Provide Self-Care Support and
Community Resources
• Support Self-Care Process
• Provide Referrals to Community
Resources

17.
Provide Self-Care Support
Use EHR to identify patient-specific education resources
and provide them to more than 10% of patients

18.
What We did
• Enhanced our website to include patient
education – accessible 24/7
• Began a monthly newsletter to inform patients
about current healthcare issues and ongoing
series such as Diabetes Today
• Began in-house Diabetes Education Classes
• Made a registry of community based
resources

19.
Standard 5
Track and Coordinate Care
• Test Tracking and Follow-up
• Referral Tracking and Follow-up
• Coordinate with Facilities/Care
Transitions

20.
What We Did
• Care co-ordination with specialists
• Continuity of care at ‘Transition of Care’
points:-hospital d/c, rehab d/c, etc.
• Clinical Care Coordinator continues to
play a role

21.
Referral Tracking and Follow-up
Demonstrate electronic exchange of key clinical
information between clinicians

22.
Standard 6
Measure and Improve Performance
• Measure Performance
• Measure Patient Experience
• Implement Continuous Quality Improvements
• Demonstrate Continuous Quality Improvements
• Report Performance
• Report Data Externally
• Use of Certified EHR Technology

23.
Demonstrate Continuous
Improvement
• Track Results Over Time
• Assessing the effect of its action
• Achieving improved performance on one
measure
• Achieving improved performance on a second
measure

24.
What We did
• Surveyed our patients to obtain their
perceptions of care and customer service
• Assessed and addressed areas for improvement
• Re-Surveyed our patients
The Importance of Surveys
Meaningful Use-2
CG-CAHPS
MOC

25.
Meaningful Use Data

26.
PCMH: one size does not fit all
• Its not for every practice….
and
• may not be needed for every patient in the practice…
• Large healthcare delivery systems seem to be adopting it first.
• Smaller practices may have challenges in such transformation.
Strategy:-
• Chronic disease = high risk patients = >High utilizers of care.
• Particular focus on the complex patients Pay 4 Performance
• Friedberg M. et al. “Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality,
Utilization, and Costs of Care”.JAMA.2014;311(8).815-825.
• Schwenk,T. “The Patient Centered Medical Home. One size Does Not Fit All”. JAMA.Feb.2014.311

27.
Consider PCMH Concepts use on
High Utilizers of Care
• Use Amazing Charts Queries to:
• cull data on subset populations…identify high risk
groups
• Identify patients that need further
intervention in care
• Identify lack of follow-up
• Resolve poly-pharmacy and medication
interaction issues at point of care

28.
Proposal for Your Practice
• Establish a ‘Clinical Care Coordinator’ in
office
• Intervene at ‘Transition of Care’ points
• Enhance communication with your
specialists
• Survey your patient perceptions of care

29.
Creating a Healthcare Delivery Team
in Your Office
Keep employees who share in the vision and mission of the
organization
 Evolve away from ‘top-down leadership’ trends into a
‘shared leadership’ philosophy
Assign specific task oriented roles to specific team
members…..
identify the strength of each employee and utilize it
but cross train all employees
‘shared decision making’---listen to patients and
employees regularly. Regular team meetings.

30.
• Questions & Discussion…….

31.
Care Management Codes
99495 - Transitional Care Management Services with the following required elements:
• Communication (direct contact, telephone, electronic) with the
patient and/or caregiver within 2 business days of discharge
• Medical decision making of at least moderate complexity
during the service period
• Face-to-face visit, within 14 calendar days of discharge
99496 - Transitional Care Management Services with the following required elements:
• Communication (direct contact, telephone, electronic) with the
patient and/or caregiver within 2 business days of discharge
• Medical decision making of high complexity during the
service period
• Face-to-face visit, within 7 calendar days of discharge