Patient-Centered Military Medical Home (PCMMH)

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Patient-Centered Military Medical Home (PCMMH)

• The Carl R. Darnall Army Medical Center
  Department of Family and Community Medicine
  Perspective

LTC Michael Wynn LTC Jim Geracci James.geracci_at_u
s.army.mil 26 Feb 2010
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Army Family Covenant

• 2.2 The Army is committed to increasing
  accessibility and quality of health care

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MHS Quadruple Aim

• Experience of Care
• Population Health
• Per Capita Cost
• READINESS

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How do we achieve these goals?

• Proposed Patient Centered Medical Home
• What is it?
• AAFP
• NCQA recognition
• Translate it to the MHS
• Office of the Chief Medical Officer (TMA)
• Myths of PCMH

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Patient-Centered Military Medical Home
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AAFP PCMH Checklist
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NCQA checklist
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OCMO 7 core principles

• Personal Primary Care Provider (PCMBN).
• Primary Care Provider Directed Medical Practice
• Whole Person Orientation (respectful, patient
  centered not disease or provider centered).
• Care is Coordinated and/or Integrated (across all
  levels of care).
• Quality and Safety (evidenced-based safe care)
• Enhanced Access (from the patient perspective).
• Payment Reform (incentivize the development and
  maintenance of the medical home).

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Patient-Centered Military Medical Home
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Patient-Centered Military Medical Home
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PCMMH Reality Check at Fort Hood, TX
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DFCM Primary Care Facilities
Copeland Center- Medical Inprocessing
TMC 14 North Ft. Hood, Provides healthcare for
activated reservists during train-up
TMC 12 Hood Army Airfield, supports 4ID
Aviation BDE
Bennett HC Supports 4th Infantry Division
soldiers and their family members
Monroe HC Supports 1st Cavalry Division soldiers
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SRP Site Bldg 42003
Thomas Moore HC Supports 13th Sustainment
Command, III Corps HQ Soldiers, AD Family Mbrs,
and Retirees/RFM
Family Medicine Residency Center Family
Medicine Residency supporting AD, ADFM, and
Retiree Care. After hours (AHC) and Weekend
(WACC) care also at this location.
West Fort Hood Clinic West Fort Hood-Gray Army
Airfield, supports 1CD Aviation BDE, other
military units, family members and retirees
Note Map is not to scale.
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Patient-Centered Military Medical Home
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Outline

• Road Map
• Practical Guide to Implementation
• Enhanced Practice Finance Is The Key
• Staffing and Team Approach To Care
• Clinic Redesign
• Removing Barriers to Access
• Defined Basket of Services
• Improved Communication With Supported Population
• Increased Focus on Population-based Care

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Road Map (or GPS) for PCMMH
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Pillars of the PCMMH
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Elements of PCMMH

• Infrastructure Principles
• Elimination of Barriers to Access
• Focus on Quality and Safety
• Enhanced Practice Finance
• Defined Basket of Services
• Advanced Information Systems
• Redesigned Offices

• Care Principles
• Patient-Centered Care
• Personal Medical Home
• Team Approach to Care
• Whole Person Orientation
• Care Provided in Community Context
• Care Coordinated and Integrated
• Focus on Quality and Safety

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Road Map

• Goal of PCMMH Improve Access to High Quality,
  Patient-Centered Medical Care and Increase
  Satisfaction of Patients, Providers, Staff
• Start With Steps That Increase Practice Revenue
  In Order to Afford the Steps That Make Practice
  Better and More Satisfying For Both The Patients
  and the Providers
• Focus on Improving the Elements of PCMMH Where
  Your Practice is Weakest
• Focus on the Practical Not the Sexy!!
• Until you Have Access the PCMMH is Just a
  Dream!!

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This Is Not the PCMMH
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Outline

• Road Map
• Practical Guide to Implementation
• Enhanced Practice Finance Is The Key
• Staffing and Team Approach To Care
• Clinic Redesign
• Removing Barriers to Access
• Defined Basket of Services
• Improved Communication With Supported Population
• Increased Focus on Population-based Care

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Step 1 Finance the PCMMH
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Step 1 Finance the PCMMH

• Sound Practice Management
• Is Not the Enemy
• Key to Financing the Dream of the PCMMH and
  Making it Reality
• Must Increase Practice Revenue
• In Order to Resource the Steps That Make Practice
  Better and More Satisfying for the Patients, the
  Providers, and Staff
• This is the Heavy Lifting Needed to Implement
  the PCMMH
• Most in both Civilian and MHS Have not Really
  Been Interested in Doing Part

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Step 1 Finance the PCMMH

• Improve Documentation and Coding of the
  Outstanding Care We Are Providing
• Usability AIM Template (along with Dragon Speak,
  etc.) Usage to Improve Documentation and Maximize
  RVU Capture
• Increase Proportion of 99213s? 99214s
• Get Your Coders Into the Clinic and On Board or
  You Will Fail!!

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Step 1 Finance the PCMMH

• Capture of Previously Uncaptured Workload/RVUs
• Nurse/Provider Triage
• Military Sick Call
• Walk-ins
• Nurse-directed care
• Military Unique Care (EFMP, Screening for
  Overseas Movement, Local Files Checks, SRP,
  Flight and Military PEs, PHAs, etc.)

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Outline

• Road Map
• Practical Guide to Implementation
• Enhanced Practice Finance Is The Key
• Staffing and Team Approach To Care
• Clinic Redesign
• Removing Barriers to Access
• Defined Basket of Services
• Improved Communication With Supported Population
• Increased Focus on Population-based Care

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Step 2 Staff the Patient-Centered Military
Medical Home

• Use the to Hire More Nurses/Staff (LVNs)
• CNAs are not Cost Efficient
• RNs are too Expensive
• High Quality and Experienced LVNs are the Key to
  Success of the TEAM CARE approach
• Need to Achieve 1.75 - 2 Nursing Staff per
  Provider to Maximize Efficiency and Effectiveness
  of Providers
• RN Nurse Case Managers on Each PCM Team
• Leverage Military Unit RNs, Medics, PTs, and
  Ancillary Support (Pharm, Rad, Lab Techs) Where
  Possible/Appropriate for Soldier Care (good for
  them and us)

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Outline

• Road Map
• Practical Guide to Implementation
• Enhanced Practice Finance Is The Key
• Staffing and Team Approach To Care
• Clinic Redesign
• Removing Barriers to Access
• Defined Basket of Services
• Improved Communication With Supported Population
• Increased Focus on Population-based Care

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Step 3 Clinic Redesign To Achieve PCMMH

• Clinics Designed around PCM Teams
• 4-5 Providers/1 RN Nurse Case Manager, Hallway
  RN, LVNs
• Nurse Case Managers
• See All New Patients for Initial Visit and Focus
  on Individual Needs/HEDIS
• F/U Visits by NCM prn for HEDIS/Ongoing Care Mgmt
• Team Approach To Care is key to PCMMH
• Ancillary Services on site for Same Day Service
  (Lab, X-ray, Pharmacy, Optometry, Audiology,
  Patient Education)
• West Fort Hood Clinic Model
• BCT Care Model/Aviation Medicine Care Model

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Outline

• Road Map
• Practical Guide to Implementation
• Enhanced Practice Finance Is The Key
• Staffing and Team Approach To Care
• Clinic Redesign
• Removing Barriers to Access
• Defined Basket of Services
• Improved Communication With Supported Population

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Step 4 Remove Barriers to Access the PCMMH
Primary Care Access
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Step 4 Remove Barriers to Access the PCMMH
Maslows Hierarchy of Needs
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Step 4 Remove Barriers to Access the PCMMH
Patient Primary Care Hierarchy of Needs
Patient Centered Care
Continuity of Care
Satisfaction with Primary Care
Quality Primary Care
Access To Safe Primary Care
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Step 4 Remove Barriers to Access the PCMMH

• Extended Hours Clinics
• Routine Appointed and Acute Walk in Care for
  Enrolled Family Members After Traditional Hours
  (1700-2100 hrs. Nightly) with Full
  Lab/Xray/Pharmacy Support
• Truly Patient-Centered Providing Care When,
  Where, How the Patients Want/Need It
• Creates Access During Traditional Clinic Hours,
  Decreases No Show Rate, and Significantly
  Increases Patient Satisfaction
• BUT , It Costs Money in Terms of Providers,
  Ancillary Staff, and Nursing Staff

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Step 4 Remove Barriers to Access the PCMMH

• Weekend Clinics
• Acute Walk-in Care and Wellness Appointments for
  Enrolled Patients (Peds, Adult, Military, Family
  Members) Every Weekend Day (except Christmas and
  New Years) from 0800-1700 hrs Sat and Sun with
  Full Lab/Xray/Pharmacy Support
• Truly Patient-Centered Providing Care When,
  Where, How the Patients Want/Need It
• Creates Access During Traditional Clinic Hours,
  Decreases No Show Rates, and Significantly
  Increases Patient Satisfaction
• BUT It Costs Money in Terms of Providers,
  Ancillary Staff, and Nursing Staff

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Step 4 Remove Barriers to Access the PCMMH

• Troop Sick Call/Walk-in Care (Truly Open Access
  for Acute Care for Soldiers Every Day When and
  Where Soldiers/CDRs Want and Need It)
• Must Do It Early (0530-0600 hrs)
• Effective and Well Documented Triage,
  Nurse/Medic-Directed Care, and Self Care are Keys
  to Success
• See Soldiers and Address Acute/Some Routine
  Issues When They Come in
• But Must Manage This or it Will Manage Your
  Clinic and Eat Your Family Care Access and You
  Will Fail Miserably in Other Aspects of
  Implementation of PCMMH for Soldiers, Family
  Members, and Retirees

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Step 4 Remove Barriers to Access the PCMMH

• QuickCare Acute Care Clinics
• Open Access Acute Care For Family Members and
  Retirees at each of our Main Clinics
• Creates Routine and Wellness Access for PCMs to
  Increase PCM Continuity While Decreasing TCONs
• Is Patient-Centered and PCM-Directed
• Patients Cared for Where and When they Want/Need
  it
• Does not negatively impact PCM continuity as
  Patients are Referred Back to PCM for More
  Complex Issues, Routine Health Care, Health
  Maintenance, etc.
• Implications for HEDIS (Can Be Screened When
  Patients Present for Acute Care)
• Provides portal for Surge Capability (H1N1,
  etc.)

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Step 4 Remove Barriers to Access the PCMMH
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Step 4 Remove Barriersto Access the PCMMH
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Step 4 Remove Barriers to Access the PCMMH

• Nurse Triage/MOD Process
• Effective Nurse Triage Team is Key
• Opens up Access as you Must Have a Way to See,
  Sort, and Address Walk-in Care, Emergent Issues,
  Ensure Patient Safety and Satisfaction, and
  Route Care to Appropriate Venues/Times/Places
• Difficult for Clinics in MHS to Address All
  Walk-in with Same Day Appointments Due to Demand
  gtgtgt Access
• Nurse-Directed Care
• Must be Appropriately Documented and Billed
• Nurse-Advice Line
• Must Support and Not Detract From Clinic
  Operations and Efforts at Improving Access (ie
  not every call should create an appt)

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Outline

• Road Map
• Practical Guide to Implementation
• Enhanced Practice Finance Is The Key
• Staffing and Team Approach To Care
• Clinic Redesign
• Removing Barriers to Access
• Defined Basket of Services
• Improved Communication With Supported Population
• Increased Focus on Population-based Care

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Step 5 Standardize Basket of Services Offered
in PCMMH Clinics
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Step 5 Standardize Basket of Services Offered
in PCMMH Clinics

• Lab
• X-ray
• Full-Service Pharmacy
• Optometry
• Audiology
• Physical Therapy
• Chiropractic
• Social Work Services
• Primary Care and Womens Health Procedures

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Step 5 Standardize Basket of Services Offered
in PCMMH Clinics

• Immunizations
• Womens Health
• Acute Care Walk-in Access (Sick call, QuickCare,
  Evening/ Weekend Care)
• Case Management Services (Military, Peds, Family
  Members)
• Comprehensive Patient Education Services (Case
  Mgrs and Dedicated Education Nurses)
• Military Sick Call
• Wellness and Routine Military Physical Exams

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Step 5 Standardize Basket of Services Offered
in PCMMH Clinics

• More??
• Physical Therapy
• Chiropractic Care
• Ambulatory BP/Cardiac Monitoring
• Pulmonary Function Testing
• Endoscopy
• Sports Medicine
• Treadmill Testing
• Mental Health Services

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Outline

• Road Map
• Practical Guide to Implementation
• Enhanced Practice Finance Is The Key
• Staffing and Team Approach To Care
• Clinic Redesign
• Removing Barriers to Access
• Defined Basket of Services
• Improved Communication With Population Supported
  by PCMMH
• Increased Focus on Population-based Care

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Step 6 Improve Communication With Population
Supported

• Open Door Policy for Patients, CDRs with Clinic
  Leadership, Support Staff/Nurse Case Managers
• Manage Empanelment
• Community Meetings/Outreach (Units, FRGs,
  Community Events Sponsored by Clinics,
  Neighborhood Meetings to Introduce Services and
  Gauge/Set Expectations)
• Office Calls with Supported Unit Commanders, FRG
  Leaders, etc.
• Strategic Communications Are Key
• Flyers, Fridge Magnets, Newspaper Articles, Other
  Media, Social Networking

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Step 6 Improve Communication With Population
Supported
Patient Portal
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Step 6 Improve Communication With Population
Supported

• Tricare on Line Potential (???) to Book Appts,
  Change PCM/Clinic, etc.
• Clinic/Hospital Web Sites, Home Pages
• Kiosks Currently not in all Clinics but Working
  Towards it for TOL, ICE, APLSS, and Patient
  Education
• Social Networking
• Clinic/Provider/NCM Blogs
• Text Messaging to Empanelled
• eVisits/Email?
• Bulk Phone Calls/Emails

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Outline

• Road Map
• Practical Guide to Implementation
• Enhanced Practice Finance Is The Key
• Staffing and Team Approach To Care
• Clinic Redesign
• Removing Barriers to Access
• Defined Basket of Services
• Improved Communication With Supported Population
• Increased Focus on Population-based Care

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Step 7 Increase Focus on Population-based Care
assessment visit
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Step 7 Increase Focus on Population-Based Care

• Chronic Disease Registries and Care Model
• AHTLA Enabled
• Population Health Integration With Nurse Case
  Management at Clinic Level is Key to Success
• Nurse Case Managers at Clinic Level
• Population Health at MEDCEN Level
• HEDIS Compliance and Remuneration
• MODS/MEDPROS for Military
• AERO for Flight Status Personnel
• Proactive Population-Level Strategies for
  Preventive Care
• Population Health Integration With Nurse Case
  Management at Clinic Level is Key to Success
• Nurse Case Managers at Clinic Level
• Population Health at MEDCEN Level

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Challenges We Must Face Up To Make PCMMH
Transformation Work

• Most Army Clinics are Space Limited
• Office Design and Flow
• AHLTA Team Documentation Issues
• Continuity of Care Issues
• OP? IP? OP Documentaton Issues (AHLTA, Essentris)
• Sister Services Care
• VA Care
• Other Military Databases (AERO, MEDPROS, etc.)
• Civilian Network Providers and Studies

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Challenges We Must Face Up To Make PCMMH
Transformation Work
MHS EMR AHLTA
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Challenges We Must Face Up To Make PCMMH
Transformation Work

• Nursing Support Model and Scope of Care
• AHLTA Encounter/ Documentation Issues
• LVN/RN Scope of Care Issues
• Triage Issues
• Hiring and Training Proper Support Staff Mix for
  PCMMH Clinics
• Empowerment is Key to Changing Staff Performance
• Expectation Management- All are Expected to be
  Part of the Care Team

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Challenges We Must Face Up To Make PCMMH
Transformation Work

• Clarification and Optimization of Relationships
  Between Supported Unit and MTF Medical Assets
• Expectation Management (MTF and Units)
• Empanelment Issues
• Roles and Responsibilities
• Integration Into PCMMH Clinics

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Pearls From The Dark Side and Way Ahead

• Transform Med has Two Things Very Right
• In Order to Succeed as a PCMMH you Must Get the
  Relationships Right
• Doctor-Patient
• Doctor-Staff
• Staff-Patient
• Clinic-Community
• Staff-Staff
• Creating a PCMH is Much More Than a Sum of
  Implementing Discrete Model Components
  Transformation is Exceedingly Difficult, and
  Those who attempt it are Heroic.

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Pearls From The Dark Side and Way Ahead

• Remove the Mystique of the Concept of PCMMH
• Focus on the Practical not the Sexy Aspects of
  PCMMH
• - Infrastructure Principles gtgt Care Principles
• We Have to Focus on Ways to Demonstrate How our
  Practices Already Have the Capabilities to
  Provide Patient-Centered Care Consistent With the
  PCMMH

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Pearls From The Dark Side and Way Ahead

• Need to Establish a Community of Care for
  Military Primary Care to Share Best Practices?
  What is Working?
• Maintain a Clear Focus on MHS Mission Priorities
  
• Wounded Warrior Care
• Support of Deployed Service Members
• AD Military Service Member Care In Garrison
• AD Family Member Care
• Retiree Care

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Pearls From The Dark Side and Way Ahead

• Given MHS Priorities
• How Do We More Effectively Integrate Soldier,
  Family, Member, and Retiree Beneficiary Care in
  the PCMMH?
• How Do We Demonstrate
• Impact of the Military-Unique Challenges on the
  Civilian Health Care Parameters We Are Evaluated
  With and Measured Against in the MHS?

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Questions/Comments???