There is a fundamental need for health care reform in the US states. CMS, under the Affordable Care Act (ACA) plans to expand patient access to care while reengineering the delivery system to provide lower cost higher quality care. For years, there has been growing evidence of fragmented care, and lack of coordination in both primary and preventive care with rising costs.
CMS, through MLN, has offered numerous articles regarding innovative programs and practices for health care providers. Dollars have been made available to provide care under programs considered innovative, offering coordinated care no matter the level of care. Besides the Accountable Care Organization(ACO), the Patient-Centered Medical Model (PCMM) has received endorsement snd support by a broad coalition of health care providers, including major health care plans, Fortune 500 companies, the AMA, and numerous specialty societies. Currently, there are over 25 multi-health plan/societal provider pilots underway in a dozen states. CMS is pushing for over 500 physician practices to practice PCMM and there are over 20 bills in 20 states promoting PCMM.
History of the PCMM
1. Since 2000, CMS has been monitoring several quality indicators and seen that states with higher spending per Medicare beneficiary tended to have lower ranking on 22 quality of care indicators.
2. The US population is projected to be 349M by 2035
902 million visits were made to physician offices in the US in 2007. 2/3 of the visits were in primary care, Peds, and Family Practice. The expected rise in care needed will be unsustainable unless new ways of delivering care are found.
3. In 2011, 10,000 individuals per day became eligible for Medicare with a dwindling supportive working population.
23% of all Medicare beneficiaries have 5 or more chronic conditions. The dollars spent account for ¾ of all Medicare spending which is for beneficiaries visiting 14 different physicians for 40 office visits annually. (Source: American College of Physicians 2007).
What is the Patient Centered Medical Model aka Patient Care Medical Home?
The Patient Centered Medical Model is a care delivery model whereby patient treatment is coordinated through the primary care physician and a guided care practitioner (an RN specially trained in this model by the John Hopkins certified program). The objective is to establish a centralized setting that will oversee office personnel that may include nutritionists and educators and encourages partnerships between physicians and their patients and families. This model monitors care delivered by Home health agencies, registries, inpatient and outpatient facilities, using information technology, health information sharing, and other means that allow a fully coordinated plan of care for the patient overseen by one notone, but numerous disjointed teams; primary care physician and the guided care practitioner, and other office personnel transforming patient care delivery. This model will no doubt be a part of local ACOs. This model requires certification and approval by CMS. Before long, it is expected state licensure will ensue.
This team may use traditional resources as well as performing a PCMM assessment, a care Gap analysis using education, collaborative meetings and retreats to design an over arching plan of care thatmonitors the diagnoses, care, progress and outcomes. This PCMM will coordinate participants in the plan of care seeking innovative proven programs delivered by quality proven health care organizations.
They will seek agencies with strong EMRs that will “speak” with their EMRs. They will seek efficiencies and innovations such as patient portals. Validated tools and evidenced-based processes will be required. Agencies should have successful validated programs available on line with the capability to have personal patient portals for messaging, lab values, communicating with the PCMM team and education modules.
The PCMM is based on four cornerstones: Provide primary care, is patient-centered, is a new model practice, and is a part of payment reform. This practice is based on 20 years of research demonstrating far better patient outcomes than traditional care.
It is truly patient centered having a primary overseer of care to eliminate the multiple physician fragmented care model. Engagement of consumers at all levels of care is expected. The PCMM is expected to find innovative methods to achieve the communication goals.
This model is endorsed by the American Academy of Palliative Care, the American Academy of Neurology , the American Academy of Cardiology, the American College of Client Physicians, the American College of Osteopathic Family Physicians, the American Geriatrics Society, the AMA, the American Society of Addictive Medicine, the Infectious Disease Society of America, the Association of program Directors of Internal Medicine, andthe Society of Critical Care Medicine. Agencies should be certain that programs developed meet the appropriate society protocols or they will not be accepted by ACOs or the PCMMs.
PCMM Major Domains and Standards
Access and Communication
- Patient Tracking Capability
- Intense Case Management
- Patient Self-Management Support
- Electronic Prescribing and Pharmacologic Review
- Test Tracking
- Referral Tracking
- Performance Reporting and Improvement
- Advanced Electronic Communication
Each standard contains sub elements, 10 of which are considered a “must pass”
Initial Level 1 is least complex care, which has 49 points for sub elements
Level 2 is Moderate care with 50-74 points. 10/10 of the appropriate sub elements must be passed.
Level 3 is Complex care with 75 points and 10/10 appropriate elements that must be provided successfully.
This is a new day for home care when present care delivery methods are rapidly changing. Your home health agency should start researching now, seeking evidenced base processes with agency research practices established, having a robust EMR and communication system. Time is of the essence. Where will your agency be in 2-6 years from now?