This is the third in a series of articles about Medical Home. Because of the newness of this concept a degree of repetitiveness is valuable in order to make sure we all understand what Medical Home is and why it has such great promise.
The most innovative aspect of Medical Home and the thing which perhaps distinguishes it from any other well-organized and well-functioning medical organization is the concept of "Coordination of Care." This is the intentional structuring, reviewing, facilitating and consistently practicing of a level of care which meets all current NCQA, CMS, national standards and HEDIS requirements for the demonstration of excellence.
The concept of "intentionality" is critical in this process. Rather than hoping the result is good, Coordination of Care plans, executes and reviews care to make certain that it meets the highest standards. In addition, patients are involved in this coordination by making them aware of the standards and giving them a periodic review, in writing, of how their care is or is not meeting those standards.
To quality as a Tier II Medical Home, a medical practice must meet 28 requirements. At present, SETMA is documenting its fulfillment of all of these requirements. Twelve of the documents are complete. Fourteen of the documents are in process sand two will be started this week. It is expected that within seven days all 28 documents will be finalized. SETMA expects to submit an application to NCQA for Medical Home status by the end of March.
The first requirement for qualifying to be a Medical Home relates to continuity of care and is described by CMS as, "The practice discusses with patients and presents written information of the role of the medical home that addresses up to 8 areas." The following is the document which fulfills the formal requirement for the first element of that application. This explanation of Medical Home which will be given to all of SETMA's patients who are enrolled in Medical Home.
Welcome to Southeast Texas Medical Associates (SETMA), LLP's
Medical Home
By James L. Holly, MD
"What did you welcome me to? " A Medical Home! This is not a new idea. The American Academy of Pediatrics (AAP) introduced the concept over thirty years ago, but in the past five years, the American Academy of Family Practice and the American College of Physicians (internal medicine) have joined the AAP in promoting the concept. The Centers for Medicare and Medicaid services (CMS) and the National Committee for Quality Improvement (NCQA) have also joined forces to promote Medical Home.
The goal is to bring you better medical care. A Medical Home is not unlike your family home. It is a place where people care about you personally and where you can trust that your interests come first. It is a place you can go when you have a need. Like your home, a Medical Home is made up of a team, each member of which has a special role, but where no one person is more important than another. It is a place where the team makes certain that all of your needs are met.
In many ways, Medical Home is like the care you have been receiving from SEMTA for years. With the use of electronics, SETMA has been able to develop systems which protect you from medical errors and which can insure that you are receiving the care you need and deserve. Now a new dimension has been added which is the Care Coordination Team (CCT). This is a team of people who focus on your needs, whether they are ordinary, like every one else's, or whether they are special needs which are unique to you. The Care Coordination Team will make certain that you get the care you need as they assess any barriers which prevent you from obtaining that care, whether it is financial, access, understanding, transportation or other.
The Care Coordination Team will also develop a plan to make sure that your needs are cared for in an emergency such as when an evacuation is ordered. Medical Home is directed toward making certain that as we increase the "high tech" aspects of your quality care, we do not lose that "high touch" care we all experienced fifty or seventy-five years ago.
The CCT led by your personal physician will make certain that your care meets national standards and will share the elements of that standard with you so that you can be confident of the quality of care you are receiving.. Measured by HEDIS and the Consortium for Physician Performance Improvement standards, your care will be evaluated each time you come to the clinic and often at times when you don't come to the clinic. When you have complex problems, the team will meet to discuss how to make sure that your care is optimal. Before you come for an appointment the team will review the state of your care to make certain that it meets the highest standards.
HEDIS is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 71 measures across 8 domains of care. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis. Health plans also use HEDIS results themselves to see where they need to focus their improvement efforts.
HEDIS measures address a broad range of important health issues. Among them are:
- Asthma Medication Use
- Persistence of Beta-Blocker Treatment after a Heart Attack
- Controlling High Blood Pressure
- Comprehensive Diabetes Care
- Breast Cancer Screening
- Antidepressant Medication Management
- Fall Risk Assessment in the elderly
- Advising Smokers to Quit
- Many other measures of care
SETMA has incorporated HEDIS standards into our Medical Home Care Coordination Review (MHCCR). In addition to the LESS Initiative (Lose Weight Exercise Stop Smoking), to which you have become accustomed, and other educational materials on your medical conditions, you will receive a Medical Home Care Coordination Review (MHCCR) each time you come to the clinic. The MHCCR will include:
- The names and contact information for your Care Coordination Team members.
- The status of your HEDIS compliance and the status of your preventive care needs.
- A list of your current medications with descriptions of your directions in plain English
- The names and numbers of emergency contacts and your medical power of attorney
- The name and number of your pharmacy as everyone who provides you care are a part of your healthcare team.
- A list of the conditions for which you are being treated.
- Information about who we are to contact in case of a mandatory evacuation so that your Medical Home can be aware if you need help in being safe.
- An assessment of any barriers to care which you have, whether they are social, financial or other.
- Any special needs they have including mobility and safety.
The MHCCR will help you take charge of your own care and for you to initiate the obtaining of the care which you need but have not received. It will allow you to judge whether you are receiving excellent care. Of course you will continue to receive the encouragement to stay active, stay healthy, eat right, lose weight and avoid tobacco.
Medical Home will enable you to continue to receive:
- Same day appointments for urgent problems.
- Immediate attention in the ER for emergency conditions
- Response by telephone or e-mail to your questions or concerns.
- Follow-up by telephone for your results of testing when appropriate.
- And, all the other contact you have received in the past.
- 24 hour a days, seven day a week access to a SETMA provider for your healthcare needs.
In addition to this, you will receive calls and correspondence from the practice about issues of general medical interest and/or things related to your personal health concerns. We believe that Medical Home is going t make you feel "right at home" with your health care: safe, confident, secure and at ease.
Welcome to SETMA's Medical Home - welcome to YOUR Medical Home. Together, we will make your healthcare experience pleasant, satisfying, excellent and successful. Welcome to your healthcare team, of which you are not only the main focus, but now you are a dynamic and critical part.
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