The Patient Care Medical Model and Guided Care: Home Health Collaboration
- As a percentage of GDP, health care expenditures are about 18%. By 2019, the national health care expenditures will be 19.3% and approaching an unsustainable level.
- CMS states: Innovative approaches to quality healthcare must be found.
New Models of Care are mandated under the Patient Protection and Affordable Care Act (PPACA) as well as naturally occurring.
CMS has identified “Triple Aim” Goals
- Better Health for the Population
- Better Care for Individuals
- Lower Cost through Improvement of Care Delivery
CMS motivates with:
- Incentive Programs: With Quality Reporting through approved programs and EHR incentives
- Payment Policies: With Accountable Care Organizations and innovative programs such as Patient-Centered Medical Homes and solid Care Transition Programs
- Quality Programs: The Programs will truly partner with the patient and Quality Care Organizations
CMS states care presently is usually:
- Uncoordinated- poor medication management, poor preventive care and overall strategies, unreliable information transfer, who to call for what?
- Unsupported- lacking standard and known process, unsupported patient activation transfer
- Unsustainable- no comment needed
Health Care delivery is changing fast. Old Medicare models in home health are being moved aside. Are you ready for Care Transitions, Patient Care Medical Models, and Guided Care? Should you be a collaborative partner with other healthcare sectors? Are you ready to assume some financial risk in a collaborative venture? There are many new innovative projects underway. Two of those new concepts include the Patent Care Medical Model with Guided Care by the Physician and RN. How would your home health agency participate in this new health care delivery process?
CMS states the Patient Care Medical Model (PCMM) rests on five pillars:
- Patient-centered orientation directed toward their unique needs, culture, values, and preferences.
- Comprehensive, team-based care that meets the majority of each patient’s physical and mental health needs.
- Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
- Superb access to care.
- A system approach to quality and safety including Care Management Interventions.
Selecting Care Management Interventions include:
CMS suggests discussing many provider and system interventions
Evidence-based Guidelines and Protocols
Provider Profiling and Reports
Registries and Clinical Information Systems
Electronic Medical Records, Decision Support Reminder System, and Other Electronic Communication Systems
Educational Brochures and Member Letters
In-Person Care Management
The Patient Care Medical Home (PCMH)
“The PCMH is intended to result in more personalized, coordinated, effective, and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location by:
- Taking collective responsibility for patient care
- Providing for the patient’s health care needs; and
- Arranging for appropriate care with other qualified
The Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
- Requires an interdisciplinary team to take responsibility to improve access, continuity, and coordination of care
- Patients and family members are engaged through education and supporting self-care and disease management
- The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person.
This program is comprehensive, team based primary care for reducing cost geared toward a collaborative model, easy to implement, capable of providing excellent care to patients with multiple chronic conditions.
Using Guided Care in this Model
- Specially trained RNs based in the PCMH physician offices.
- The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions.
- The nurse and her “back-up” RN partners with the patient for the rest of the patient’s life.
This model was initiated in 2002 by John Hopkins University.
The RN will converse, assess, and create an evidence-based Care Guide (notice they chose “guide” not “plan”).
The Guided Care RN coordinates care with other care providers, HH providers, clinics, and hospitals.
The Guided Care RN educates and supports family and caregivers.
This RN also identifies community services that are most appropriate for this patient and her needs.
Physicians planning Guided Care Can receive:
Free Technical assistance at:
Online courses from John Hopkins Nursing available for RNs,
There are also Physician and family courses
Order the free Implementation Manual:
Guided Care: A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families.
Guided Care is
A collaborative approach, physician directed-Nurse assisted, that truly works with the patient to achieve education, accomplish goals, and allieve anxiety from lack of continuity
A proven evidence based team approach that includes care planning, care transition, education, and support
Look at Kaiser
Look at Vanguard Medical Associates
Piedmont Community Health Plan
Home Health Agencies Interested in Collaboration
Look for innovative partnerships
Offer same day access and response
Look at creative tools needed; specialized programs.
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs.
Find consistent communication methods and processes.
Establish proactive, prepared, practice teams.
Be willing to break away from the traditional Medicare model of care.
Consider shared risk.
Home Health Agencies should
Be willing and available of leadership and clinicians to “up-skill.” Be flexible. Be rapid in response.
Be willing to work COLLABORATIVELY.
Agree to have certain clinicians trained in PCMH constructs.
The HH agency should see improvements in goals attained.
The HHCAHPs should reflect the patient satisfaction.
New Innovations and New Types of Care Delivery
Together we can invent and create our way to success. We can work together for a individualized, sustainable, proud new American Health Care System. Better care is overall less costly care. No matter how we view the new models, they are going to augment and eventually could replace the present model. Your thoughts?