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PCMH transformation takes governance, determination, EHR savvy

By Jennifer Bresnick

- The patient-centered medical home (PCMH) is often seen as the end product of a long list of major changes to the way providers deliver care.  By aligning financial incentives, data-driven quality improvements, a personalized approach to care, and a robust population health and chronic disease management infrastructure, the PCMH provides the ideal ecosystem to keep patients healthier for longer while driving down costs.

But such a massive transformation doesn’t happen overnight, and it doesn’t happen easily, warns Michael Meucci, Director of Transformation and Improvement at Arcadia Healthcare Solutions. It takes a huge amount of organizational dedication and a solid roadmap.  Meucci sat down with EHRintelligence to discuss how organizations can achieve success with the PCMH model.

What do you consider the definition of the patient-centered medical home?

There are two definitions of PCMH in my mind.  There are PCMHs as defined by getting everyone in the organization – not just the care team, but organizational leadership, as well, bought into this notion of driving care with a focus on care quality and really focusing on the patient.  And that’s not just a physician leadership thing.  It is really, truly something that needs to be adopted in the mantra of the organizational leadership.

And then there’s a medical home as defined by being recognized by the Joint Commission or AAAHC for example.  And there is a difference.  They’re kind of overlapping, because there are some people who are recognized as PCMHs who still operate in the fee-for-service model.  There are some people who are not officially recognized who operate in the full-blown medical home style.  And then there’s varying degrees of those combinations across the spectrum.

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What are some of the challenges involved in transitioning to this model of care?

What we see being problematic is that the medical home is a really resource-intensive model.  You go from having a physician who has a one-on-one relationship to a patient to a team-based model where a team has a relationship with the patient.  And I think that that works really, really well for your sickest and your most chronic patients.

But I think what we’re still trying to figure out as a system is how the medical home works for those who are kind of mid-risk patients. They might have an emerging chronic condition, or are at risk of developing one. How do we keep them from kind of moving further down that risk pathway?

And then what are we doing about the 60 percent of patients who are low risk, like the people who are young, or just starting families?  You know, they’re active.  They don’t have chronic conditions.  How do we keep them in that risk profile and keep them not only low-cost, but keep them healthy?

And I think one of the challenges of the medical home is that it has kind of been this one-size-fits-all, or at least it’s been perceived as this one-size-fits-all solution.  But really, the optimal solution is having a care-management strategy that really focuses on segmenting your population into those different risk categories and making sure you’re putting the appropriate resources around them.

What are some of the key ingredients for success when considering a shift to the PCMH model?

When we look at some of our most successful transformations, we see strong leadership buy-in.  In one of the projects that we’re working on that is really, really successful, the CEO was the one who said, ‘We are going to do this.  We’re going to transform the medical home.  We’re going to provide the highest quality care in our region, and failures not an option.’

From there, they built a steering committee that was made up of representation from the executive leadership team, practice leadership, medical leadership, and technology leadership.  It was really every functional area of that organization that was represented on this team of six.

It facilitated communication. It put this lens in the back of everyone’s mind, so whenever they were making decisions, they thought about how those choices would impact the medical home program.

So when they started looking at potentially replacing their EHR, instead of being a decision that was made in a silo, it was brought to that governance team, and they said, ‘Okay, we’re thinking about replacing our EHR with a newer, more robust tool.’ The governance team said, ‘Okay, well, great.  That’s good to know, but here are all the changes we’ve made to our current platform to support our medical home.  We need to make sure that’s all possible with a new system.’  So the decisions that were being made weren’t being made in a box.  They were being discussed to make sure that they weren’t impacting the organization or the medical home program negatively.

What made this project so successful is it has really, really tight governance around it.  They all met regularly, and they all had very specific, focused missions when it came to how they were going to impact the program.  And they all knew that.

How can organizations who feel overwhelmed by competing initiatives focus themselves to take advantage of what the PCMS has to offer?

You know, I think health care gets such a negative rap because everyone’s like, ‘Oh, costs are too high, and no one cares.’  Costs are high. I would agree with that.  But I wouldn’t argue that no one cares.  You have a lot of competing priorities.

If you look at the average health care organization, they have two or three different payer-led pilots they’re trying to participate in.  They have meaningful use.  They might be trying to do PCMH.  They might be replacing or optimizing their EHRs.  So, there’s just so many things going on, and there’s no integration of them.

I think what happens sometimes with PCMH is that it kind of gets lost in the fray because it takes so long to transform.  It’s typically a 12- to 18-month endeavor.  If you’re looking to get recognized by one of the accrediting bodies, you’re looking at a pile of documentation and reports that need to be collected and proofread and reviewed and the whole nine yards. It can get lost in making sure that your physicians are hitting their meaningful use targets, or making sure that you’re hitting your quality targets for pay for performance contracts.

But there is a very large, single, consistent thread running through all of those programs, and if they’re all managed separately by separate departments, you’re missing the opportunity to find the synergies and implement one program.  Find the commonalities.  They’re all quality programs, and they’re all focused on how to use data more effectively.  And if they’re running through different groups that uncoordinated, it does create a lot of extra overhead that’s unnecessary.  That tight governance structure is really, really important.

The other piece is having dedicated resources.  A lot of times I see organizations that hire an outside consultant, and they think that means they’re going to be a medical home in no time.  But there’s no consideration of the fact that there are going to be IT changes, or there needs to be time that care teams are not practicing, and they’re learning about how to change their model and talking about how to change their model. A lot of the transformation process is thinking and talking about what they can do differently.  Because there’s no such thing as a medical home that comes ready-made in a box. It looks different for every organization.

How can providers leverage the technology they already have to aid this transition?

You need to make sure you are maximizing the use of your EHR.  Sometimes that means that before you embark down the road for transforming to medical home, you need to square away your EHR optimization program.  Make sure that people are using it properly, and that you’re back up to acceptable levels of productivity.  Because the PCMH is another big change, and productivity is probably going to dip in the short term.  If you’re compounding that dip with your EHR implementation dip, it makes it look like the medical home has caused a massive decrease in productivity to someone who may not be aware of all the different factors going on.  That can change the perception around the initiative.

You might have a physician who says, ‘I was seeing 30 patients a day before we started the medical home program, and now I’m seeing 20.’  But what you’re really seeing is that the physician was seeing 30 before you implemented an EHR. You implemented an EHR, and you started to see 24, and now you’re doing this medical home training, and there’s time away from practice to get trained and implement change, and now you’re seeing 20.  So it’s just compounding issues that were already there.

But if you can get back your productivity and efficiency after EHR implementation, get it optimized, and make sure you’re using it meaningfully, then that negative impact of productivity is minimized, and it also keeps the spirits of everyone participating in the program higher so you can be more successful.

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