4/19/2012 The Patient-Centered Medical Home What is our Role? Objectives By the end of this session, the audience member should be able to: Michelle Cudnik, PharmD May 3, 2012 OSHP Annual Meeting 1. List 2011 Patient-Centered Medical Home standards 2. Demonstrate ways to integrate a pharmacist into these standards 3. Discuss the implications of the surgeon general report to pharmacy services 4. Define the accountable care organization model and the role of a pharmacist in it Case Case WR is a 54 yom who presents to the Ambulatory care clinic with a chief complaint of “ran out of my insulin” HPI: patient newly started on insulin (1 month ago). Given samples of insulin at that time. PMH: Type II DM (5 years ago), insomnia, tobacco use, Hypertension, Neuropathy  Why a new model of primary care? Future of Ambulatory Care  Institute of Medicine Report 2001, “Crossing the Quality Chasm” – – – – Less than 50% of patients with major chronic illness receive accepted treatments Less than 50% have satisfactory disease control Focus on episodic and not continuous care Little attention given to the patient’s knowledge, skills, behavior in managing their own illness Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21 st Century. Washington DC. National Academy Press; 2001  Vitals: BP 160/80 (repeat 158/82), HR 88, Temp 98.2 Wt 178lbs BMI 27 Pertinent labs: HgA1c: 10.8% LDL 124, HDL 32 TG 149 SCr: 0.59 Microalbumin/Creat ratio: 11.8  1. 2. 3. 4. 5. 6. Six urgent aims for improvement: Safe Effective Patient-centered Timely Efficient Equitable Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21 st Century. Washington DC. National Academy Press; 2001 1 4/19/2012 Patient-Centered Medical Home   Patient-centered, physician-guided, costefficient, longitudinal care that promotes continuous healing through relationships and delivery of care by a “team” of health care providers Funded by national grants, state Medicaid pilot programs, and the Affordable Healthcare for America Act (Reform bill) via demonstration projects Patient Centered Care **Shift in mindset**  Involve perceptions, goals and knowledge of the patient when creating therapeutic plans for their care  Shift from physician-centered care by using thoughtful standardization and meaningful measurements The Advanced Medical Home. American College of Physicians Policy Monograph, 2006 Background for Medical Home Model   Concept of a medical home first emerged in pediatrics, where it was recognized that children with special needs would benefit from a delivery model that effectively coordinated the complex clinical and social services that many patients require Reinforced by Wagner and colleagues in form of chronic care model- coordinate outpatient care for complex, oncology patients 2011 Patient-Centered Medical Home Standards       Enhance Access and Continuity Identify and Manage Patient Populations Plan and Manage Care Provide Self-care and Community Support Track and Coordinate Care Measure and Improve Performance National Committee for Quality Assurance 2011 Wagner EH. JAMA 2002; 288 (15) 1909-1914. Must-Pass Elements       PCMH 1; element A: PCMH 2; element D: management PCMH 3; element C: PCMH 4; element A: PCMH 5; element B: follow-up PCMH 6; element C: quality improvement access during office hours Use data for population Certified PC Medical Home   care management support self-care process referral tracking and National Committee for Quality Assurance (NCQA) has 3 levels of recognition Each level reflects the degree to which a practice meets the requirements of the elements and factors that compose the 6 standards implement continuous 2 4/19/2012 Recognition Levels    Level 1: 30-59 points and all 6 Must-pass elements Level 2: 60-84 points and all 6 Must-pass elements Level 3: 85-100 points and all 6 Must-pass elements Identify and Manage Patient Populations    The practice collects demographic and clinical data for population management The practice assesses and documents patient risk factors The practice identifies patients for proactive and point-of-care reminders Enhance Access and Continuity    Plan and Manage Care     Provide Self-Care and Community Support    The practice assesses patient/family selfmanagement abilities The practice works with patient/family to develop a self-care plan and provide tools and resources Practice clinicians counsel patients on healthy behaviors and medications Patients have access to culturally and linguistically appropriate routine/urgent care clinical advice during and after office hours The practice provides electronic access The focus is on team-based care with trained staff The practice identifies patients with specific conditions, including high-risk or complex care needs Care management emphasizes: – Assessing patient progress toward treatment goals – Addressing patient barriers to treatment goals The practice reconciles patient medications at visits and post-hospitalization The practice uses e-prescribing Track and Coordinate Care   The practice tracks, follows-up on and coordinates tests, referrals and care at other facilities (e.g., hospitals) The practice follows up with discharged patients 3 4/19/2012 Measure and Improve Performance     The practice uses performance and patient experience data to continuously improve The practice tracks utilization measures such as rates of hospitalizations and ER visits The practice identifies vulnerable patient populations The practice demonstrates improved performance So… What can we do?       American Academy of Family Physicians- Position Statement   January 2012- Intent of paper was to define nature of collaborative relationship between the physician and pharmacist AAFP recommendations: - vaccine administration only occur in the medical home/physician office setting (due to fragmentation of care) 2011 Surgeon General Report    Titled- Improving Patient and Health System Outcomes through Advanced Pharmacy Practice Report provides rationale to support health reform through pharmacists delivering expanded patient care services and promote advocacy to have CMS recognize pharmacists as providers Report is framed around 4 focus points that present evidence-based data that illustrates improved health care delivery through pharmacist- delivered patient care Translate EBM to the patient (algorithm development) Education to patients and physicians Interprofessional patient care/Collaborate Medication reconciliation Medication safety Medication intensification American Academy of Family Physicians- Position Statement  AAFP recommendations: - supports health care professionals working together where the physician is the coordinator of the patient care and the pharmacist is the member of the integrated team - only licensed doctors of medicine, osteopathy, dentistry and podiatry should have prescriptive authority Four Focus Points 1. 2. How Pharmacists are already aligned into primary care as health care providers How to sustain value-added patient care services delivered by pharmacists - Must be recognized as health care provider by statute via legislation and policy 4 4/19/2012 Four Focus Points Accountable Care Organizations How to sustain value-added patient care services delivered by pharmacists - Must be compensated through additional mechanisms commensurate with the level of services provided 4. Discusses and collates the numerous articles, systematic reviews and metaanalyses of positive patient and health system outcomes that have been published  Accountable Care Organizations Core Functions of the ACO 3.    Method of integrating primary care physicians with other members of the health care system and rewarding them for controlling costs and improving quality. An effective ACO should include a pharmacist or a pharmacy division that supports clinical goals! Key is to look at prevention and wellness Potential barriers to Health Care Reform    How will we get the resources needed upfront to provide highest quality care at lowest cost? Will outcomes be able to be measured? Will financial reimbursement occur?   Healthcare reform highlights the need for hospitals, providers along the care continuum, physicians, and patients to work collaboratively to ensure appropriate, high quality, efficient, and cost-effective delivery of healthcare Primary goal of ACOs is to reduce the total cost of care for a given population while maintaining and improving quality and satisfaction. CMS will recognize voluntary ACO’s in 2012 “Accountable Care Organizations: A new model for sustainable innovation”, Deloitte Center for Health Solutions, 2010      Facilitating provider partnerships with patients, families and communities Redesign primary care medicine and advance the medical home concept Integrate the health care system across the continuum of care Provide tools and resources to health care providers Population health management Pharmacy Practice Model Initiative  To develop a future practice model platform that is responsive to healthcare reform and the health system of the future  Learn more at: http://www.ashp.org/PPMI/PPMISummit.aspx 5 4/19/2012 Five Practice Models 1. 2. 3. 4. 5. Drug Distribution Clinical Specialist Patient Centered Integrated Patient Centered Hybrid Model- Faculty Comprehensive Patient Centered Back to our case…  Enhance access and continuity- Team based care - Patient seen regularly for diabetic planned visits - Patient seen by social worker for insulin assistance programs/test strips, dietician and gets lab work drawn in clinic Pharmacist Integration at a Residency Clinic   Patient Centered Integrated model Pharmacy residents and students trained to perform medication reconciliation, support and initiate outcome based improvements, work closely with the care team on diabetes Back to our case…  Identify and Manage Patient Populations: - Part of diabetic planned visit schedule - HgA1c every 3 months until at goal - Pertinent lab work added to electronic record as reminder  Plan and Manage Care- Assessment of patient to reach treatment goals and assess barriers to reaching his goals - Medication reconciliation Back to case…  Provide self-care and support - Set self management goals and follow-up - Counseling/education provided to patient - Smoking cessation support  Track and coordinate care- Summary    - Referrals for podiatry, dental, ophthalmology  We have a unique and exciting opportunity with the health care reform underway Our involvement with direct patient care is right in front of us We must lobby and market ourselves NOW so to be a key provider in patient care in the future Remember- it’s all about the patient! 6 4/19/2012 QUESTIONS?? 7