Project Option 2.1.3: The Development of a Primary Care Medical Home in a Health Professions Shortage Area.
Unique Project ID: 84597603.2.1
RHP Performing Provider / TPI: TEXAS TECH HS CTR FAMILY MED / 084597603
Project Description:
The purpose of this project is to establish the Department of Family Medicine Kenworthy Clinic as a Primary Care Medical Home. By doing so, we will improve overall chronic disease management and promote health outcomes in the target population.
Project Goal: The goal of this project is to develop the Department of Family Medicine Kenworthy Clinic as a Patient Centered Medical Home (PCMH) model of care delivery, offering improved chronic disease management and health promotion outcomes, and expanded access and training to family medicine residents in the delivery of care in the PCMH setting. This will enable our trainees to implement the concepts of a PCMH in border and underserved settings upon graduation. We will use evidence based change concepts for practice transformation developed by the Commonwealth Fund’s Safety Net Medical Home Initiative.
The Department of Family Medicine fully embraces the concept of the medical home and is eager to complete the process. Up to this point, the primary challenge has been the funding resources to recruit the non-physician providers to the team; a particular challenge given our high proportion of indigent and Medicaid patients.
We have chosen improvement targets which focus on the care of patients with diabetes. One of these, annual eye exams, will be particularly challenging to meet given the profound shortage of ocular care professionals in the Region.
From the patient perspective, the challenge will be to help patients understand the concept of the medical home, and understand how to fully utilize the benefits such a model provides to them. As we complete the process milestones in DY2, patient education will be a significant part of the roll-out. Likewise, Process metric-13 will include patient educational planning to address this need.
Goals and Relationship to Regional Goals: A number of providers in our region are proposing efforts to increase access to primary care and utilize the primary care medical home model. Even with these regional efforts, primary care will be seriously under-manned in our Region.
5-year expected outcome for patients and providers; the Family Medicine Clinic at Kenworthy will be accredited by the NCQA as a PCMH, fully integrating non physician and physician providers into care teams, and will be fully utilizing a disease management registry to manage populations of patients at risk. Patients will have access to a team based approach to their care, and identify Kenworthy as their medical home.
Challenges: The major challenge in completing the designation as a medical home has been related to costs of building the infrastructure of provider and non-provider personnel required, as well as the necessary administrative support to manage the endeavor.
Baseline: We have already taken initial organizational steps based on the standards of a Patient Centered Medical Home in order to deliver culturally sensitive, coordinated, integrated, and comprehensive care with improved access and including high quality care from a personal physician and practice team. We have already implemented advanced access scheduling including a well-established open access model that allocates 30% of appointments each day to same day request and we have a modern EMR that meets meaningful use criteria and supports evidence based protocols. The Family Medicine Clinic is a self-contained, 24,000 sq. ft. clinic that offers a full spectrum of adult and pediatric acute and chronic care.
Rationale:
Primary care in RHP 15 is in a state of crisis. In 2010, the Paso del Norte Foundation sponsored a region wide planning symposium addressing and documenting health care needs in a broad area which includes Region 15. This survey documented that Texas counties comprising Region 15 have profound needs in primary care providers. Using nationally recognized benchmark data, the survey estimated the Region needed three hundred and sixty four Family Medicine, General Internal Medicine or General Practice Providers (1). This situation will worsen as more patients are insured under the Affordable Care Act (2).
The Family Medicine Clinic at Kenworthy represents an ideal model to create a PCMH. The clinic is a self-contained, 24,000 sq. ft. facility that offers a full spectrum of adult and pediatric acute and chronic care. It is located in a Health Professions Shortage Area for both primary care and mental health care. Our population suffers from a disproportionate burden of chronic diseases. The BRFSS 2010 self-reported rate of overweight and obesity, risk factors for diabetes, in PHA Region 9/10 is 67.5 %, while the nationwide rate is 64.3. Over 70% of El Paso residents are of Hispanic ethnicity, an additional risk factor for diabetes. Therefore, most of the population is at risk for diabetes. Indeed, the self-reported rate of diabetes in El Paso is 12.8%, compared to a nationwide self-reported rate of 9.3%. This becomes even more significant as the population ages. The self-reported rate of diabetes in El Paso increases from 6.4 % when less than 45 years of age to 19.1 % for ages 45 to 64 and to 28.5% for ages 65 and older. The overall impact of this particular chronic disease is huge, and 37.1% of BRFSS respondents from El Paso report no health insurance, compared to a nationwide rate of 15.1%.
The population served by PLFSOM is particularly at risk. Across the outpatient care enterprise, roughly 35% of our patient visits are provided to patients without any 3rd party coverage, and an additional 35% are provided to patients with Medicaid. Given the profound shortage of primary care providers, it is very difficult for unfunded or underfunded patients to access primary care for chronic conditions, and simply not realistic to assume that a medical home model will evolve spontaneously in such an under-served market.
As we have developed EMR capabilities, and worked with managed care providers to look at HEDIS quality measures, we see that there are significant opportunities to improve the care of patients with diseases common in the Region. For example, looking at 2011 date from one of our managed Medicare providers, we note that roughly half of our patients had an eye exam or HbA1c testing in the past year. We believe that completing the transition to an accredited Patient Centered Medical Home will be a significant step toward improving such metrics.
Project Components: we chose project option 2.1.3. As particularly relevant to our population and Kenworthy’s location in a HPSA. We will complete all components of this project option:
a) Empanelment: Assign all patients to a primary care provider within the medical home. The steps necessary to achieve this are part of the process milestones in DY2. In DY3, we will complete the actual assignment of patients to medical teams.
b) Restructure staffing into multidisciplinary care. This is accomplished in Milestone 1 in DY2.
c) Link patients to a provider and care team so both patients and provider/care team recognizes each other as partners in care. This will be accomplished as part of Process metric P-7 in DY3
d) Assure that patients are able to see their provider or care team whenever possible. As part of the process of reorganizing into care teams, we will develop training for schedulers to be able to identify the patient’s medical team and schedule appropriately.
e) Promote and expand access to the medical home by ensuring that established patients have 24/7 continuous access to their care teams via phone, e-mail, or in-person visits. Our organization is already committed to establishing a patient portal linking providers, our EMR and patients. As part of this initiative, medical home patients will have access to secure email communication as well as existing phone and in-person visits.
f) Conduct quality improvement for project using methods such as rapid cycle improvement. We will incorporate this element by including status of the PCMH as a standing agenda item on the weekly Department meeting.
The next steps in completing our transition to a patient centered medical home are to 1) expand the advanced access services by developing the Infrastructure (clinical staff, providers and administrative staff) to offer evening and weekend clinics to our patient population, and we will implement e-visits, group visits and home visits as well. The expanded access will enable patients to access their practice and providers at times more suitable for them and their families and reduce visits to urgent care facilities and emergency rooms where often unnecessary care and tests are conducted; 2) Develop a multidisciplinary team approach to improve patient care for those with chronic diseases. We will utilize professionals from other disciplines working alongside providers in managing chronic diseases inside and outside of the traditional practice setting. We will integrate community nurses, dieticians and pharmacists into practice teams with physicians and mid-level providers to optimize chronic disease management and assist in the care of patients recently discharged from hospital, as well as for non-compliant patients in a culturally sensitive manner. The pharmacist will advise on polypharmacy issues and be able to assist with our elderly and chronic disease afflicted population to reduce drug interactions and optimize existing medication regimes; 3) Develop innovative approaches to Health Promotion and Screening: A navigator will use the patient registry to identify and track patients through the health promotion and screening program. We will integrate community health (Outreach) workers, dieticians and nurses with physicians and mid-level providers into practice teams to optimize health promotion, health screening and disease prevention educational sessions within communities in a culturally sensitive manner; and 4) We will train our family medicine residents on the principles of the PCMH so that they are skilled in working in a PCMH setting. Since most West Texas medical residents stay within a 75 mile radius of their training site to set up practice (3), and greater than 80% of our graduating family medicine residents choose to serve in medically underserved areas (including RHP 15), our residents will be trained to replicate this model in these communities upon graduation.
The milestones proposed for this project build from the current state of readiness of the clinic to establish a PCMH, and reflect the remaining process steps necessary to complete this transition. These include reorganizing the staff into teams, defining the criteria to be enrolled in a PCMH, enhancing communication options between providers and patients, and implementing a recall system to demonstrate the ability to identify populations of patients who would benefit from additional services. The improvement targets include obtaining a nationally recognized accreditation as a PCMH, and to improve screening rates for two conditions which significantly impact our population, namely eye disease in diabetes and breast cancer.
As the single largest multi-specialty provider group in the Region, and the largest provider of primary and specialty care within the Region, PFLSOM provides nearly 250,000 outpatient visits a year. The development of Patient Centered Medical Home within the Paul L. Foster School of Medicine Department of Family Medicine represents the best opportunity to integrate care management, primary care and necessary consultative services through a single provider referral network and EMR to meet well documented needs of our unfunded and underfunded patient base.
How the project represents a new initiative or a significant expansion of an existing healthcare delivery system reform: This project represents a significant expansion of the efforts the Kenworthy Family Medicine Clinic has made to date to becoming accredited as a primary care medical home. As noted above, they have undertaken a series of steps within existing resources to begin the process. To complete the process requires adding infrastructure and non-physician providers to formalize the concept of a “team”. In addition, it requires the infrastructure support to develop methodologies to track relevant clinical metrics and to develop and implement alternative communication strategies.
Category 3 Related Outcomes:
IT-1.12 Diabetes care: Retinal eye exam—NQF 0055 (Non- standalone measure)
IT-1.13 Diabetes care Foot exam- NQF 0056 (Non- standalone measure)
IT-1.14 Diabetes care: Microalbumin/Nephropathy NQF 0062 (Non- standalone measure)
Relationship to Other Projects and Measures: This project is closely linked with other projects we are proposing:
1) 84597603.1.2 - The establishment of a disease management registry within the Paul L. Foster School of Medicine. This project will initially focus on diabetes in the Department of Family Medicine, and subsequently, the Department of Internal Medicine. Diabetes represents a high impact disease in our population, and coordinating resources to this condition is critical to success.
2) 84597603.1.1 - Expansion of Specialty Care in Ophthalmology: As defined more completely in that project narrative, we have a critical shortage of Ocular care professionals caring for high risk patients. We can document poor compliance with recommended screening examinations. Impacting this issue will require a data registry, expansion of ocular care professionals and tracking and recall efforts as proposed in this project.
Relationship to Other Providers’ Projects in the RHP: A number of providers in the Region are offering proposals to enhance primary care access in the region, and UMC is proposing to establish medical homes in their primary care clinics as well.
Plan for Learning Collaborative: The performing provider will participate in semi-annual learning collaboratives within the RHP addressing access issues and the expansion of medical homes.
Valuation: The Performing Provider considered a series of factors in establishing a valuation for each project. These included the amount of human resources required to meet the milestones of the project, through new hires as well as the assignment of existing support personnel such as Information Technology, EMR and administrative support. We considered what non personnel resources would be required, such as equipment specialized for a certain specialty, and what, if any, additional space would be required to house the initiative. We considered timing issues related to when we had to add resources compared to when a corresponding milestone could be achieved. We also considered the amounts of potential professional fee revenues the project may generate, and offset these against resource demands.
We made a risk assessment for each project, considering the complexity, the scope, the extent to which any single point failure in the milestones would jeopardize downstream success, the degree of inter-dependence on other projects within the waiver program as well as institutional initiatives outside the waiver, and the amount of time required to manage the project. We made an assessment of potential general community benefit.