March 2014 Newsletter

Studies Examine Impact of Southeast PA Medical

Home Initiative 

 

Two new studies examined the impact of Patient Centered Medical Homes (PCMH) in Southeast Pennsylvania (SE PA). Both looked at the experience of practices participating in the multi-payer supported SE PA regional rollout of Pennsylvania's Chronic Care Initiative (CCI) compared to a control group of practices or patients.

 

The first study, published in the Feb. 26, 2014, issue of the Journal of the American Medical Association (JAMA) found little quality improvement and no cost savings in the PCMH practices compared to the control practices. The study is contrary to numerous other studies showing significant quality and cost saving gains from medical home implementation. 

 

The second study, published in the March 2014 issue of The American Journal of Managed Care (AJMC), likewise found no overall differences in utilization or costs between the PCMH and control practices, but found significant differences in both utilization and costs for high-risk patients with complex needs. The PCMH practices achieved statistically significant decreases in utilization of inpatient services for high-risk patients in all 3 years studied (2009-2011), and statistically significant decreases in per member per month costs for high-risk patients in the first two years compared to baselines (2008).

 

The first study conducted by researchers at RAND, Inc. and the University of Pennsylvania was part of a statewide evaluation of Pennsylvania's Chronic Care Initiative (CCI), which at one time involved nearly 150 primary care practices in 7 regional rollouts across the state. The JAMA article focused only on the first regional rollout in SE PA that ran from mid-2008 to mid-2011. Additional publications are expected describing the impact of the initiative in other regions of the state.

 

The second study was conducted by statisticians and medical leaders at Independence Blue Cross, the health plan with the largest market share in SE PA. It concluded that the PCMH model is achieving its intended effect of enabling providers to better assess patient needs and proactively coordinate care to prevent clinical crises that require expensive hospitalizations, particularly for the highest risk patients.

Members of the PA SPREAD team also studied the experience of the practices participating in the SE PA CCI under a research grant from the Agency for Healthcare Research and Quality (AHRQ). A series of papers have come out of that research, including a positive deviance analysis of what factors and practice characteristics facilitated medical home implementation in the most-improved practices compared to the least-improved practices. As that study showed, there was widespread variation in key clinical diabetes measures across the 25 adult medicine practices that focused initially-and almost exclusively-on diabetes improvement.

 

Given this variation in quality improvement and focus on diabetes patients, it is not surprising that the RAND evaluation found minimal aggregate quality improvement (gains in the most-improved practices may have been offset by less improvement in the least-improved practices) and no reductions in the total cost of care or utilization for the entire patient population served.

The SE PA practices did show statistically significant improvement in the RAND study on a variety of structural changes related to medical home implementation over the three-year initiative. These include:

  • Providing quality feedback to PCPs.
  • Monthly or more frequent meetings about quality.
  • Use of a registry for identifying patients overdue for chronic disease services, out of target range for chronic disease laboratory values, and at high risk of disease complications or hospitalization.
  • Care management for patients at high risk of disease complications or hospitalization, to help patients better manage their diabetes, and to routinely assess self-management needs in chronic illness.
  • Use of outreach systems to contact patients due for services related to diabetes, breast cancer screening, and after hospitalization.
  • Electronic medication prescribing and laboratory test ordering.
  • Use of the electronic health record to document patient medication and problem lists.
  • Secure messaging to and from patients.

PA SPREAD advises practices on the medical home implementation journey to focus their efforts on process redesign around providing proactive population management for all patients, including planned care at every visit, self-management support, and care management for the highest risk patients. More information on each of these topics is available on the PA SPREAD website.

ICD-10: Is Your Practice Prepared?

 

On October 1, 2014, ICD-10 codes will replace ICD-9 codes for reporting medical diagnoses and inpatient procedures. ICD-10 codes are more precise and provide enhanced information. ICD-10 codes have been used in other countries since 1995 (United Kingdom) with success.


EHR vendors are working to accommodate ICD-10. Learning your vendor's plans, timelines, etc. will help to ease the transition. In addition,

CMS is offering industry emails that you can subscribe to as well as a Provider Resource Guide that includes:

 

AmeriHealth has released coding exercises and scenerios available for public use. The latest release of ICD-10 codes can be found here. 

NCQA Releases 2014 PCMH Recognition Guidelines

 

In Pennsylvania, most primary care practices that have pursued Patient Centered Medical Home (PCMH) recognition have applied for recognition from the National Committee for Quality Assurance (NCQA).

 

NCQA this month released updated PCMH recognition standards for its 2014 recognition program. Compared to NCQA's 2011 PCMH recognition standards, the new 2014 standards require:

  • Further integration of behavioral health.
  • Additional emphasis on team-based care (making team-based care a "must pass" element).
  • Care management for high-need populations.
  • Involvement of patients/families in practice management.
  • Alignment of quality improvement activities with the "triple aim" of improved quality, cost, and experience of care
  • Alignment with health information technology Meaningful Use Stage 2.

Practice teams that are interested in applying for NCQA PCMH recognition may want to plan to apply under the 2011 standards. The 2014 standards are seen as "raising the bar" on the 2011 standards, as the 2011 standards did on NCQA's initial 2008 PCMH recognition standards. 

 

The deadline for purchasing NCQA's 2011 survey tool is June 30, 2014. After that, only the 2014 version will be available. The survey tool is a sophisticated Excel spreadsheet that applicants must use to document their compliance with NCQA's recognition standards. It costs $80 per practice and can be purchased online. 

 

The deadline for applying for recognition under NCQA's 2011 program is March 31, 2015. This timetable gives applicants 9 months to complete and submit the 2011 survey tool from June 30. Applicants should allow several weeks for the submission process, and must document PCMH policies, processes, and structures that have been in place for at least 3 months. Please plan accordingly.  NCQA offers a variety of live and on-demand webinars that describe the PCMH recognition process, standards, and survey tool. 
Best Practices Spotlight


The Alexander Spasic, MD, office in Carlisle has created a Personal Appointment Planner that patients complete in the waiting room prior to being roomed. The planner asks patients questions on their immunization status, diet/exercise, chronic diseases, and preventive screening needs as well as their concerns for that day.

As patients are roomed, Medical Assistants cover the identified gaps in care. The practice has found that by asking the patient to take part in planning for their appointment, they are more activated during their time with the provider.
In The Literature
 

The 10 Building Blocks of High-Performing Primary Care 

 

Case study research on high-performing primary care practices coupled with practice facilitation experience and literature review identified 10 building blocks of high-performing primary care practices:

 

  1. Engaged leadership.
  2. Data-driven improvement.
  3. Empanelment.
  4. Team-based care.
  5. Patient-team partnership.
  6. Population management.
  7. Continuity of care.
  8. Prompt access to care.
  9. Comprehensiveness and care coordination.
  10. Template of the future that allows for fewer and longer in-person visits and greater use of e-visits and visits with non-provider team members.

 

The researchers note there may be multiple pathways to implementing these building blocks.

 

Systematic Review of the Application of the Plan-Do-Study-Act Method to Improve Quality in Healthcare

 

Many primary care practices that are working to improve their processes and patient outcomes have used the Plan-Do-Study-Act (PDSA) methodology to test changes on a small scale before widely implementing them.

 

A new study from the U.K. suggests that improvement could be even better with more consistent and reliable application of the PDSA method.

 

For instance, too few improvement efforts appear to be tested on a small scale first, adhere to the idea of iterative improvement cycles to refine ideas being tested, or rely on data to inform the progression of testing cycles.

Joint Principles for Integrating Behavioral Health Into the Patient-Centered Medical Home

Six national Family Medicine organizations have endorsed and released Joint Principles for Integrating Behavioral Health Care into the Patient-Centered Medical Home.

 

The Behavioral Health Joint Principles build on and are intended to supplement the original Joint Principles of the Patient-Centered Medical Home first released by the organizations in 2007.

 

In the new Joint Principles, behavioral health encompasses mental health care, substance abuse care, health behavior change, and attention to family and other psychosocial factors.

 

The Joint Principles state that:

 

  1. Every patient in the PCMH should have a personal physician who knows them and is committed to their well-being.
  2. Care should be provided through a physician-directed team/neighborhood of health care professionals, including behavioral health specialists.
  3. Whole person orientation is not possible without integrating behavioral and physical health.
  4. Behavioral health care should be coordinated and integrated with physical health care.
  5. Behavioral health care information should be incorporated with appropriate security and privacy measures into the medical record.
  6. Patients should have open access to behavioral health care.
  7. Payment should appropriately recognize the added value of integrated behavioral health and enable behavioral health clinicians to share in the cost savings associated with coordinated care.

 

The Joint Principles note the following critical issues that need to be addressed:

  • Agreement on clear and consistent language across disciplines.
  • Understanding of the central role of the patient and family in developing care plans.
  • Clear definition of roles and responsibilities across the health care team.
  • Interdisciplinary training.
  • Research to better define the optimal provision of whole-person health services.
  • Adaptation based on regional or local needs.
  • Assurance that behavioral health services are included in all benefit plans. 
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