On February 17, 2009, four SETMA colleagues attended a physician-leadership conference in Houston to hear an introduction to the concept of a Patient-Centered Medical Home. Conducted by two representatives of the American Academy of Family Practice, the conference raised more questions than it answered. On February 19, 2009, the first of this series of ten articles on Medical Home, entitled, Part I: Is it the future of healthcare?, appeared in The Examiner. Thus began SETMA's 15-week journey through a maze of information, publications and discussions about what a "medical home" is.
The Beginning
On February 18, 2009, at 7:00 AM, I sent the following note to SETMA's team:
"As I lay in bed last night thinking about the Medical Home, I got up and recorded a few thoughts some of which are below. This begins to answer for me the issue which I raised last night. If we accomplish what I have briefly outlined below and if we implement its use, after fleshing it out so that it is comprehensive, I think we will take all of the elements of Medical Home, all of which we already do and we will create the synergy which Medical Home promises. We are a very long way away, but this is a first step."
The question I asked last night, which was not answered, is, "If we are doing everything you say that a Medical Home should do, and if we are not now a Medical Home, which I am confident that we are not, what is missing?" No one could answer that question but it continued to plague me.
It became apparent, and it became the focus of SETMA's design, that there are two core issues to Medical Home
- The patient is the central focus and it is the intent of Medical Home to engage the patient in their own care, empowering them with knowledge and ability to direct and evaluate the quality of that care.
- The coordination of care must now be "intentional" rather than simply "incidental" to other forms of care. At each visit, the primary care provider must have as his/her goal, the organization and completion of care in three areas: preventive care, acute care and chronic care.
As a result, the February 18th note continued with the following comment:
"...The below is what is missing from our discussion last night. The "connector" for all of the elements of care which we are doing is the Medical Home Care Coordination Database and Review which we do not have."
CMS and NCQA Requirements for Medical Home Recognition
As part of our Medical Home initiative, SETMA reviewed the 28 requirements identified by the Centers for Medicare and Medicaid Services (CMS) for qualification as a Medical Home and did an extensive analysis of SETMA's fulfillment of those requirements. The result was a 419-page document which analyzed SETMA's care in light of CMS' requirements.
We had our challenge for the redesigning, restructuring and re-engineering of our work flow and patient encounters to fulfill all of the elements of Medical Home. The enormity of that task became more evident as we reviewed the National Committed for Quality Assurance's (NCQA) standards for being recognized as a Medical Home. In their recognition process, NCQA identifies 9 standards, 30 elements and 183 data points.
Because participation in CMS's Medical Home program requires being recognized by an accreditation agency, SETMA chose to apply to NCQA for recognition as a Medical home. The intentional coordination of the patient's entire care and the inclusion in that collaboration of all of the standards, elements and data points of the NCQA model became the goal of our development of Medical Home.
After numerous meetings, reviews and discussions, SETMA's leadership felt that we could quality for a Tier 1 Medical home, which is the lowest qualifying level. However, we wanted to quality as a Tier III, which is the highest. In addition, rather than just fulfilling 75 out of a possible 100 points, in order to achieve a Tier III Medical Home, SETMA wants to achieved higher than a 95-point recognition. The task now was much larger. Rather than completing an NCQA Medical Home application in March, 2009, we decided to complete a remodeling of SETMA's healthcare delivery and to apply to NCQA in September, 2009.
At 7:45 AM, on February 18th, I sent the following note to SETMA's staff:
"I do not pretend that anything I wrote below is new. Such information is collected by many different parts of our system - there are even ICD-9 Codes for social situations such as "lives alone" etc.
"The thing which I think is novel and which may be the energy behind Medical Home is where the healthcare provider, who is identified by the patient as his/her principal healthcare provider, has all of this information which is:
- Comprehensive
- Accessible
- Considered in medical decision making for the patient
"Creating the database for this information is the 'first thing.' Making that database interactive and dynamic is the 'second thing.' Using that database in an active and inter-active means in the care of patients is the 'third thing.'
"Under the Medical Home model the provider has NOT done their job when they simply prescribe the best care which meets national standards of care. Doing the job of Medical Home requires the prescribing of the best care which is available to the patient."
At 10:13 AM, on that February 18th morning, the following preliminary view of the Medical Home Coordination of care
When compared with the layout and functionalities of the completed Coordination of Care Review template which is reviewed below, it will be seen how this process slowly began to give form and substance to the comprehensive coordination of patient care.
On April 14, 2009, I summarized some of our progress with the following note:
"Yesterday, I asked my assistant to tally the number of pages of materials which we have possessed in our Medical Home pilgrimage. I was amazed to learn that it is 2,280 pages, contained in 9 notebooks with material from NCQA, CMS, NQF, and PQRI, along with over 600 pages of materials which have been produced and written by SETMA staff. This has been a prodigious effort and a Herculean project. We are virtually at the end of the beginning.
"...by the end of this year, at the very latest, we expect to have incorporated into our EMR and into our work flow evidence-based standards and structure of healthcare , with the capacity for each provider to daily evaluate their own performance at the point-of-care, from:
- Healthcare Effectiveness Data and Information Set (HEDIS)
- National Committee on Quality Assurance (NCQA)
- National Quality Forum (NQF)
- Physician Consortium for Physician Performance Improvement (PCPPI)
- Physician Quality Reporting Initiative (PQRI)
- Patient Centered Medical Home (PCMM) - in process, application to be submitted in September
- E-prescribing
As this is written, June 2, 2009, all of the above is complete and the data to support the NCQA application is being collected daily. The application for NCQA recognition will be completed in September, supported by the data which we began to collect on June 1, 2009.
The following is the Medical Home Coordination Review template. Comparing this with the preliminary template from February 18th lets you see how far we have come. This template has been in use for over a month and all of SETMA's are becoming experience in how to use it.
All of SETMA's healthcare providers and most of our nurses have completed the review and study of a 99-page tutorial on how to effectively use this template in the performance of the Coordination functions of Medical Home. In addition, each has completed a comprehensive test on this tutorial indicating their knowledge of its content and of how to use this tool in the midst of seeing patients.
In addition, they have reviewed a shorter, 7-page tutorial, on how to complete the evidence-based preventive health care and patient evaluation measures required by NCQA, which have not traditionally been part of routine patient care, but which are a critical part of the intention improvement of patient care.
Auditing Provider Performance
For the next two-weeks, SETMA's information technology department staff (IT) is involved in installing and in being trained on the use of a robust "data mining" software tool which will enable providers to know "how they are doing."
When completed in two-weeks, all members of SETMA's healthcare team will receive a daily audit on the patient encounters from the previous day. This audit will include:
- The number of elderly patients who have medications which have been identified as being potentially hazardous to the patient. This review will include the following information:
- Was the medication reviewed and discontinued?
- Was the medication reviewed and changed?
- Was the medication reviewed and needs to be continued?
- Was the medication and the action discussed with the patient?
- HEDIS evidence-based quality measures. This audit will include a report of how many measures applied to each patient and how many were completed.
- NQF evidence-based quality measures. This audit will report how many patients had all of their NQF measures fulfilled and how many did not.
- PQRI evidence-based measures. This will be audited as for HEDIS and NQF.
- Physician Consortium for Performance Improvement in Diabetes
- Physician Consortium for Performance Improvement in Hypertension
These audits will be automated and will be reported to each provider at 6:00 AM. Each month, SETMA's aggregate data on all patients seen will be posted to our website so that all of our patients can know how SETMA is performing and how SETMA is improving in our quest to become an effective Medical Home.
There are other data points required by NCQA which are not a traditional part of healthcare providers' attention or documentation. Some of those were discussed in Part IX of this series. Our auditing will indicate to us how we are coming in areas such as having written "plans of care" and written "treatment plans" on our patients.
This is not an easy process, but the result will be improved and excellent care for all for our patients. That result is worth the energy, effort and resources which SETMA is putting into this process. We look forward to reporting to you in the fall that SETMA has been recognized by NCQA as a Tier III Medical Home. Until that time, we continue to work toward continuing to provide the best care to our patients, which is the only care they deserve.
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