The document provides an overview of the Patient Centered Medical Home (PCMH) model as implemented in the Army Medical Department. It discusses the history and principles of the PCMH approach, including having a personal physician, care coordination across different providers and settings, a focus on quality and safety, and enhanced patient access. The Army's experience to date includes establishing PCMH teams in 11 medical treatment facilities, with plans to expand implementation in phases to improve patient experience, health outcomes and costs.

1. Patient Centered Medical Home The Army Medical Department Experience 29 April 2011 Gary A. Wheeler, MD, COL Western Regional Medical Command CMIO

2. “The views expressed are those of the author and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.” Slide 2 of

3. Board Certified, Internist Fellow, American College of Physicians Education: BS, UC Berkeley; MD, USUHS Residency: Walter Reed Army Medical Center Member, Army Medical Department PCMH WG Internal Medicine Consultant, OTSG Past jobs: Department Chief, Madigan Army Medical Center Deputy Commander for Clinical Services (CMO), Weed ACH Chief, Clinical Informatics, MAMC Chief, Internal Medicine Service, MAMC Staff Internist, Walter Reed; Moncrief ACH, Ft Jackson, SC Who Am I?

4. Terminal Learning Objectives Define Patient Centered Medical Home Understand PCMH History Identify principles of patient centered care Review the current evidence for patient-centered care Review the 2008 and 2011 NCQA standards Review PCMH implementation in the Army Medical Department Introduce the Comprehensive Care Plan PATIENT CENTERED MEDICAL HOME

6. Model in caring for children with special needs

7. Single source of patients’ medical information (medical record)

8. Grew to include a partnership approach with families to provide primary health care

9. Accessible

10. Family-centered

11. Coordinated

12. Comprehensive

13. Continuous

14. Compassionate

15. Culturally effective

17. Four groups

18. American Academy of Family Physicians (AAFP)

19. American Academy of Pediatrics (AAP)

20. American College of Physicians (ACP)

21. American Osteopathic Association (AOA)

22. Represent 333,000 physicians

24. Physician directed medical practice

25. Whole person orientation

26. Care is coordinated and/or integrated across all elements of the complex health care system

27. Quality and Safety

28. Enhanced Access to Care

30. Could be a specialist or subspecialist for patients requiring ongoing care for certain conditions

31. Severe asthma

32. Complex diabetes

33. Complicated cardiovascular disease

34. Rheumatologic disorders

35. Malignancies

36. HIV

38. The personal physician

39. Leads a team of individuals at the practice level

41. Not disease centered

42. Not provider centered

45. chronic care

46. preventive services

48. Hospitals

49. Home health agencies

50. Nursing homes

52. registries

53. information technology

54. health information exchange

55. other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

56. PATIENT CENTERED MEDICAL HOME Care is Coordinated and Integrated across all levels of care

58. Outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family

59. Evidence-based medicine and clinical decision-support tools guide decision making

61. Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication

62. Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.

66. Identify and Manage Patient Populations

67. Plan and Manage Care

68. Provide Self-Care Support and Community Resources

69. Track and Coordinate Care

70. Measure and Improve PerformanceAchieving NCQA standards will require the AMEDD to optimize all existing IT technologies by aligning them with defined PCMH care delivery processes.

71. PCMH 2011 Alignment with Measures of Meaningful Use E-prescribing – medication list, allergies Patient tracking/registry – demographics, diagnoses, vital signs, smoking, population management, insurance Care management – reminders for follow-up care, decision support, RX reconciliation Electronic capability – e-health info. to patient, visit summary, e-access to health information, provider information exchange Performance reporting/improvement

73. Focus on Medicare beneficiaries, primary care-based care coordination with team models featuring nurse care coordinators, EHR decision-support, and performance incentives.

74. Two year follow-up results:

75. Better quality: Statistically significant improvements in quality of preventive (74.0% improvement), coronary artery disease (22.0%) and diabetes care (34.5%) for PCMH pilot practice sites.

76. Reduction in costs: statistically significant 14% reduction in total hospital admissions relative to controls, and a trend towards a 9% reduction in total medical costs at 24 months.

79. Pilot clinic had an absolute increase of 4% more of its patients achieving target levels on HEDIS quality measures

80. Patients also reported significantly greater improvement on measures of patient experiences, such as care coordination and patient activation.

81. Better work environment

82. Less staff burnout, with only 10% of pilot clinic staff reporting high emotional exhaustion at 12 months compared to 30% of staff at control clinics, despite being similar at baseline;

83. Major improvement in recruitment and retention of primary care physicians.

84. 29% reduction in ER visits 11% reduction in admissions.

86. Creating Alignment: Military Health System Quadruple Aim Readiness Pre-, During, and Post-deployment Family Health Behavioral Health Professional Competency/Currency Population Health Healthy service members, families, and retirees Quality health care outcomes A Positive Patient Experience Patient and Family centered Care, Access, Satisfaction Cost Responsibly Managed Focused on value Quadruple Aim as an Enduring Construct for Care 26

87. Army Medical Home:Experience to Date

88. 35 Hospitals (Parent Sites) 114 Child Sites PCMH early adopters 11 MTFs with 66 PCMH Teams No NCQA recognized sites yet PCMH in Army Inventory 10 of 11

89. OPORD 11-20 published Feb 2011 9 of 11

90. Army PCMH Model PCMH ratios. 2 exam rooms per PCM 3.1 support staff direct staff who work for a single PCM shared staff who work among several PCMs in the PCMH Team < two exam rooms per PCM, the enrollment cap will be reduced accordingly

94. Phase 1: Build the Team and Patient Centered Experience of Care Duration: 6-12 Months Phase 3: Implement Advanced Medical Home Practices Duration: 6-12 Months Phase 2: Manage Demand Duration: 6-12 Months Team STEPPS Staff Roles and Responsibilities Building the Patient Partnership Service and Communication Standards Patient Centered Workflow The Huddle Empanelment Access Management E-visits Care Coordination Population Health Comprehensive Care Plan Advanced Access Team Care

95. Army Medical Home Transformation Plan Three phases: 1. MEDCOM trains Regional transformation teams in San Antonio (Apr 26-28 2011) 2. Regional teams assess MTF readiness and develop MTF-specific transformation plans. (May-Jun 2011) 3. Regions oversee and support MTF transformation plans. (Begin NLT Sep 11)

96. Phase 1 Concept of Operation 1. Command guidance Training topics: TSG on PCMH and standardization, Critical Performance Measures, PBAM, Funding, Work Force Transformation 2. Franchise Model of Operations (based on CBMH model) Integrates Team STEPPS and Customer Service training already slated for Army-wide roll-out. 3. Transformation support Informatics, Logistics, Facilities, Marketing and Strategic Communications 4. Expanding the Team and Scope of Practice Integrated Behavioral Health, Post-deployment Health, Pharmacy, Health Promotion and Wellness, Subspecialty Care, Pain Management

97. Key Points Community-based and MTF-based PCMH are integrated Key leaders for vision, strategy, and implementation plan support both versions of Army Medical Home CBMH initiative is “clean slate, start from scratch” version MTF MH initiative is “transformative” version EHR Workflow reengineering is critical piece for both initiatives Secure Messaging will begin deployment this year CBMH’s are first priority Team-based workflow and processes must be in place first Ongoing Tri-Service integration efforts – will be essential component of our success Common experience of care Resourcing Metrics Payment reform

98. Community based medical homes

100. Improve access to and continuity of care

101. Facilitate Patient-Centered Medical Home

102. Reduce emergency room episodes

103. Improve patient and provider satisfaction

104. Implement Best Practices & standardize services

106. The Screaming Eagle Medical Home Experience 29 Nov- Staff assembled for training, TSG ribbon cutting 29 Dec- Open for patient care 12,585 Square feet of leased space on Clarksville Gateway Hospital campus Pharmacy, Moderate Complexity Lab, Tx Room, Vax onsite Radiology from Blanchfield or Gateway 5/6 PCMs,1 float and Psych NP on-hand

107. Typical Appointment Greeted by Patient Care Coordinator LPN takes to room, presents orientation packet, acquires vital signs, med reconciliation, allergies, PMH, SHx, acquires HPI, conducts ROS, identifies age appropriate preventive medical and wellness requirements, and documents all. Conveys pertinent data to Provider Provider engages patient, expounds on history, conducts PE while nurse documents findings Assessment and Plan formulated, orders input. Care plan completed Physician exits; nurse educates patient as needed Warm handoff to lab, pharmacy, Care Coordinator as needed

108. Military treatment facility army medical homes

109. FY 2010 ATC Metrics: Dunham Clinic DUNHAM CLINIC % MEDCOM % TARGET % PRIMARY CARE MANAGER (PCM) CONTINUITY PRIMARY CARE MANAGER TEAM CONTINUITY 60% 85% HEDIS ARMY PROVIDER LEVEL SATISFACTION SURVEY (APLSS) 52 WEEK AVG. 90% 85.5% Q9 – OVERALL PHONE SERVICE Q13 – STAFF COURTESY / HELPFULLNESS Q10 – CONSIDERATE SCHEDULE Q14 – COORDINATION OF VISIT Q11 – TIME BETWEEN SCHEDULE & VISIT Q21 – OVERALL VISIT SATISFACTION Q12 – WAIT TIME Q11 – TIME BETWEEN SCHEDULE & VISIT Q12 – WAIT TIME

111. 22 internists / nurse practitioners

112. IM residency continuity clinic

113. Annual well-come visits Nov 2009

114. Pre-visit HEDIS review, lab / rad

115. 30 minute LPN screen pre-visit

117. Source: APLSS

118. Sources: a) RVU’s per FTE per Day – Decision Support Center b) MEDCOM Target 16.04 RVU’s/FTE/Day – Decision Support Center

119. Sources: a) RVU’s per encounter – Decision Support Center b) Workload RVU’s per E/M Code – Decision Support Center c) National Average – ACP Practice Management Center

120. Source: June 2010 PIFA Report

121. Source: June 2010 PIFA Report

122. Source: June 2010 PIFA Report

123. Source: June 2010 PIFA Report

124. Source: June 2010 PIFA Report

125. Source: June 2010 PIFA Report

126. Source: June 2010 PIFA Report

127. Army Medical Home:Comprehensive Care Plan

128. Patient Care Landscape - Current CPGs RGs Consults Registries Discharge Summaries Essentris ED note

130. Physician directed medical practice

133. Integrating Care Delivery Pathways:The Comprehensive Care Plan Concept Slide 61

135. Population Health

136. Readiness

137. Per Capita CostSpecialist Specialist Specialist PCMH CCP ACO Patient All CCP activities are recognized allowing better attribution of value to MHS strategic outcome measures. Slide 62

139. Automated: Makes proactive requests for care activities

140. Integrated: Organizes information logically from all data sources Comprehensive Care Plan (CCP) 7 of 11

144. All CCP Elements copy forward from AIM to AIM within the Triservice Workflow AIM Group

145. Standard CCP 7 Condition Blocks (each ties to a CPG) Metabolic Syndrome (DM, HTN, HLD, Obesity) Asthma/COPD Low Back Pain CV Disease Depression/PTSD/SPMI Pain Management Substance Abuse 68

146. CCP – 7 Core Items Diagnosis Goal of Therapy: (Generally pre-populated – example “A1C <7, BP <130/80, LDL<100, BMI <25) Actionable data: (Generally pre-populated with name of data – example A1C: 8.2 on 12/16/10) Co-managing Team/Consultants: (“Which cooks are in the kitchen?” - nurse/tech will ask pt the 1st time this is documented, any additions can be added by ordering provider) Barriers to achieving goal: Provider-driven entry (requires judgment) Timeframe for f/u: Provider-driven entry Patient’s goal for next appt: Provider-driven entry, negotiated between provider and pt at today’s visit (example: cut smoking rate in ½, exercise additional 1 hr/week, lose 2 lbs, take meds as prescribed) Ideally, provider only has to enter these 3 fields. Additional data can be added at provider discretion and copied forward. The above 7 items are the minimum standard for CCP. 69

147. New Patient To Your Clinic 36 year Old female How do you learn of this patient? How should you learn of this patient? In a PCMH Clinic what should you do when you learn of your new patient? 70

148. Initial Intake Pro-active data gathering 71

149. Chart ReviewConducted Prior to Visit By Nurse Records review Seasonal allergies Hyperlipidemia BMI 30 Generalized anxiety Family Planning OCP’s Smoker 72

150. Now What? Provider Concerns Smoking / OCP use Quit smoking Lipid management Weight loss to BMI 25 73

151. Intake Nurse Visit Patient Concerns Husband deployed Two children under age 8 (one with ADD) Full-time job Worries all the time 74

152. Put It All Together(shared decision making) Individualized Comprehensive Care Plan (CCP) Pt satisfied with SAR tx if she can stop sneezing and itchy eye and not feel tired from any medication (has a job and kids) Pt has been thinking about quitting smoking but too much stress right now (contemplative stage with barriers) Willing to stop her OCP to reduce stroke risk since husband is deployed anyway Willing to see someone about her anxiety but doesn’t want to start any medication that will “knock her out or get her addicted” Wants help with her “hyper child” causing her a lot of stress and she gets very frustrated with him. She has tried to lose weight many times and will be stressful right now to lose all the weight needed to get to BMI of 25 but willing to work with team to achieve 10% weight loss to reduce risk of medical complications 75

153. QUESTIONS ? gary.a.wheeler@us.army.mil 76