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Patient-Centered Medical Home Is a “Pragmatic” Shift in Care

By Jennifer Bresnick

- Becoming a patient-centered medical home takes a great deal of hard work and a steady commitment to continual practice improvement.  To achieve the coveted Level III NCQA recognition, providers must operate at peak performance, leveraging health IT to bring coordinated, high-quality population health management to their communities.

Patient-centered medical home recognition

But the patient-centered medical home (PCMH) recognition brings more than bragging rights to successful organizations.  As payers get serious about value-based reimbursement, providers that align themselves with emerging care delivery strategies may be in line for some financial success, as well.

At Valley Health Partners (VHP), the Physician Hospital Organization (PHO) centered at Holyoke Medical Center in Western Massachusetts, achieving PCMH recognition has been one part of the region’s overall acknowledgement that coordinated, value-based care is the wave of the future. 

After significant investment in EHR infrastructure and a close working partnership with the Massachusetts eHealth Collaborative (MAeHC), Valley Health Partners took an incremental approach to PCMH recognition that emphasized manageable, meaningful steps towards embracing the high level of quality care its business partners are now demanding.

“Health New England, which is one of our local payers, was beginning to explore this budding concept of patient-centered care, and they really very much wanted us to dangle our feet in the water,” said Dr. Robert M. Fishman, DO, FACP, in an interview with HealthITAnalytics.com.

READ MORE: NCQA Revamps Patient-Centered Medical Home to Ease Adoption

The program didn’t start with patient-centered medical home recognition as its ultimate goal, but as a more tailored accountable care project that would bring Valley Health Partners physicians a year-end bonus for meeting certain quality benchmarks for Health New England patients, Fishman explained. 

With MAeHC’s help, Valley Health Partners had already made a concerted effort to participate in the EHR Incentive Programs close to the beginning of the meaningful use era.  Most providers had chosen to implement a single vendor’s EHR products, which made further efforts to coordinate care across the community that much simpler.

“We set up a very modest program with Health New England, where we would pick a couple of diagnoses in internal medicine and a couple of diagnoses in pediatrics and we would begin to set up policies and think in a more patient-centric way to reach certain goals,” he said. 

“We concentrated on CHF and COPD, because those two conditions produce a lot of readmissions and emergency department visits.  There’s a lot of expense.  If we could really get a handle on those conditions, we could improve care, improve outcomes and decrease costs.  Three things that we're all very interested in.”

After several years of focusing on diagnosis-specific population health management, MAeHC had an interesting proposition for building on the organization’s success. 

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“The Mass eHealth Collaborative approached us and they said, ‘You know, if we do an assessment of each of your practices in terms of the 2011 criteria for NCQA PCMH accreditation, we can find out how far away you are from actually doing a patient centered medical home for all of your patients, not just your Health New England patients, and becoming NCQA certified,’” Fishman explained.

The National Committee for Quality Assurance framework for PCMH recognition demands a number of data-driven quality improvements from potential applicants, including individualized care management, a heightened emphasis on chronic disease care, referral tracking and care coordination, and a plan for sustained improvement over time.  For some providers, the process seems daunting.  For Valley Health Partners, it was just a continuation of what was already being accomplished.

“During the assessment, our MAeHC consultants found that we weren't too far away,” Fishman said.  “We had a lot of work to do, but a lot of it had already been done.  And if we could ramp up our efforts, we could probably get it done.”

“Most of us signed up for it.  A couple of providers opted not to.  Two providers who were still using paper-based workflows opted in, and we went ahead,” he continued.  “The eHealth Collaborative helped train our staff, and they stayed on us to make the necessary improvements.”

“We started using our patient portals to send messages to patients when they hadn’t been seen for a year, or they were overdue for a mammogram or a colonoscopy.  It was very easy to communicate with patients and say, ‘Hey, you're a diabetic and you haven't been seen in five months.  You should have been in two months ago.  Set up an appointment.  We've got things to discuss.’”

READ MORE: CT Medical Society Announces New Health Information Exchange

Implementing the workflow changes that support the patient-centered medical home requires a shift in perspective that can be challenging to some providers who feel overwhelmed by the basic necessities of providing care.  Expanding access to care is one of the fundamental “must-pass” requirements for recognition, but can be stressful for organizations that have trouble juggling their patient schedules.

“We changed the philosophy in all of our practices when it came to patient access to same-day appointments,” said Fishman.  “It used to be that we would have emergency slots that we could fill if someone needs to be seen, but now we think of them as same-day appointments.”

“If a patient calls and they want to be seen, put them in.  Patients are more likely to call if they don’t think that it has to be some sort of emergency for us to let them in.  That’s not what we want them to think.  We want to reduce as many barriers to quicker care as possible.”

The effort has paid off handsomely.  “We found out last month that everyone who committed to the patient-centered medical home initiative succeeded,” Fishman was pleased to report. “And everyone succeeded at Level III, with the exception of the two paper-based practices.  Going into it, they knew that the highest they would be eligible for was Level II, because they didn’t have an EHR, and they made Level II.  So we think this was a slam dunk, massive success.”

Fishman credits the achievement largely to the slow-and-steady pace of practice transformation his organization has adopted.  “We got our staff onboard with all these changes by doing the pilot project with Health New England,” he explained.  “So by the time we said that we're going to do this full tilt, it wasn't really a major shift.  It was just an expansion of what we were doing already.”

“We started out with a few slow baby steps.  Those baby steps became larger steps for about two to three years.  And then the state assessment that was done showed that hey, we're not that far from the finish line.  So it wasn't an overnight deluge of issues.”

The cultural and organizational changes that made patient-centered medical home recognition a possibility were rooted in Valley Health Partners’ approach to EHR adoption when the EHR Incentive Programs first enticed physicians to invest in health IT by offering financial rewards.   

“We felt we should adopt electronic health records because we couldn't get past thinking that if the federal government wants to spend $44,000 on every single physician in this country, they must be pretty serious about it, and we shouldn’t be blind to that,” Fishman recalled.

“I think that providers who haven’t adopted EHRs by now are all behind the eight ball, because things are moving quickly, he added. “A lot of the payers looking at contracts with us want to know that we're doing patient-centered activities, and that we're beginning to do registry work and population health management.”

“The biggest challenge is always physician buy-in and physician engagement,” he acknowledged.  “I think we've done a very, very good job of engaging the physicians and getting them to understand what we’re trying to accomplish.”

“And even if they don't philosophically agree with it, which is fine, they know that this is how reimbursement is going to look as we move forward.  We have seen that there has been no increase in fee-for-service payments by most of the insurance companies for the past few years.  They want us to report on quality measures.  They want us to raise the level of care.  So if you want to get paid, be a pragmatist and get it done.”

EHR adoption, coupled with such significant operational change, isn’t without its pitfalls, Fishman admitted.  Productivity has been a casualty of the process, even as Fishman dedicates more time to consulting with his patients to provide them with the personalized care they crave. 

“I spend a lot more time with my patients now, and the kick in the head is that I don't really want to spend less time with them, because we all find it very satisfying to work together like that,” he said.  “The patients have responded well to this.  They enjoy when we reach out to them by letter or by portal.  They respond favorably.”

“But since adopting the EHR, I have been very slow to get back to my baseline productivity, which has hurt me financially.  My documentation is far greater than it's ever been, and that takes time. And I'm home at nights documenting, which I don't like.  But I'm hopeful that as our value-based reimbursements take off, I might be able to get back to what I once was financially, without cramming in 25 patients a day,” he added.

While there may be negatives that must be mitigated, EHR adoption and the patient-centered medical home has helped to coordinate care across the Holyoke community.  Dr. Fishman has some simple advice for other healthcare providers who are investigating the PCMH as a way to invest in the care strategies and frameworks that will support future value-based reimbursement structures.

“Number one, get an EHR,” he stated.  “Number two, work with someone who is invested in your wellbeing, like your local hospital.  Number three, start out slow and have realistic goals.  And when you achieve those goals, set out new goals.  And number four, which is absolutely important, have a consultant that knows what they're doing.”

“We couldn’t do any of this without our consultants,” he reiterated.  “We have a lot of folks here who are pretty sharp and savvy with health IT, but this wasn’t their niche.  We needed to consult with someone who really understood the patient-centered medical home and everything that had to go into it.”

“The folks that work for the Massachusetts eHealth Collaborative have been certified in doing this stuff, and they're very good at what they do.  And I applaud them for that.  I know they applaud us for the hard work that we've done.  Just like every other part of the patient-centered medical home, you need to take a team-based approach to healthcare.”

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