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Medical Home: How does it intersect with

genetics?Ingrid Larson BA, MSN, MBA, RN, CPNP

Learning Session 2November 8-9, 2013

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Disclosure• I have no relevant financial relationships

with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity.

• I do not intend to discuss an unapproved/ investigative use of a commercial product/device in my presentation.

• NOTE: Some of the slides were adapted with permission from a slide deck provided by Michelle Haley, MD at Children’s Mercy Hospital

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Objectives• Review the patient centered medical

home (PCMH) model and define the need for the CYSHCN population

• Review the basic components of the medical home model, including NCQA PCMH recognition

• Discuss how the GPCI QuIIN project fits with this model

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PCMH History•1967: Concept first introduced by the AAP

•2001: The IOM’s Crossing the Quality Chasm: A New Health System for the 21st Century – patient centered

•2002: AAP policy statement with components defined

•2007: Joint Principles of the Patient-Centered Medical Home is put forth by the AAP, AAFP, ACP, and AOA

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PCMH Building Blocks

• Personal provider• Provider directed practice• Whole person orientation• Coordinated care• Quality and safety• Enhance access• Payment reform

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PCMH ComponentsAAP• Accessible• Family-centered• Continuous• Comprehensive• Coordinated• Compassionate• Culturally effective

NCQA• Primary care providers• Practice team

– Defined roles– Regular team meetings– Standing orders– Training for

• Coordination of care

• Self-management• Communication

skills

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PCMH Participants• Primary care provider• Family• Child / youth• Nurses and allied health care

professionals• Family’s community• Pediatric office staff• If necessary, pediatric sub-specialists

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PCMH Process• Care Teams (providers, nurses, care assistants,

scheudlers, RT, social work• Empanelment• Changed schedules / increased access• Pre-visit planning / standing orders• Data monitoring

– Clinically important conditions (preventive, acute, cost)

• Follow-up phone calls– ER / UCC and inpatient

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What does PCMH do?• Research shows:

– Fewer ER visits– Fewer hospital readmissions– Fewer inpatient admissions– Lower per capita cost– Estimated cost savings– Improvement in medication

management– Care coordinator positions hired

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IHI Triple Aim

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• Improving the patient experience of care (including quality and satisfaction);

• Improving the health of populations• Reducing the per capita cost of

health care.

http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx

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PCMH Transformation

Current Care ModelReactive

Physician‐CenteredFragmented

Address reason for visit onlyMy patients are those that have an 

appointment todayPatients are responsible to coordinate their own care

PCMH ModelProactive

Patient‐CenteredCoordinated

Care determined by proactive planOur patients are those that are registered in our medical homeA prepared team coordinates all 

patient’s care

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Who can PCMH serve?

• Everyone…

• But especially Children and Youth with Special Health Care Needs (CYSHCN)

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CYSHCN definition• The share of children under age 18

who are at increased risk of a chronic physical, developmental, behavioral, or emotional condition, and who also require health and related services of a type or amount beyond that required by children generally.

• More than 12 million U.S. children meet the definition of CYSHCN

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Source: Maternal and Child Health Bureau

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CYSHCN Need

• Approximately 40,000 CYSHCN in the United States, or 13% of children, have a special health care need.

• Approximately 1 out of 5 homes in the United States has a child or youth with special health care needs

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CYSHCN across the U.S.

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http://datacenter.kidscount.org/data/acrossstates/Map.aspx?loct=2&ind=29&dtm=299&tf=18

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CYSHCN Financial Reality• CYSHCN alone account for 80% of pediatric

health care expenditures• Annual cost of providing medical care to

CYSHCN– Hospitalization: 61%– Specialists: 14%– Durable medical equipment: 5%– Primary care: 5%– Other: 15%

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CYSHCN Reality for families• 39.5% indicate their child’s or youth’s

condition impacts family’s financial situation

• 13.5% say they spend 11+ hours/wkcoordinating care for their child or youth

• 24.9% indicate families cut back on work due to child’s or youth’s condition

• 28.5% indicate families stop working due to child’s or youth’s condition

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CYSHCN Reality for practices• Time

– Clinical evaluation– Record reviews– Patient/Family counseling and education– Coordination of services

• Clinic Environment / Resources– Physical clinic space / accessibility– Staffing / personnel comfort and training

• Electronic resources and documentation• Unfamiliarity with the patient / family• Reimbursement

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Changing health care climate

• In response to health care reform, the medical home model has been presented as the answer to the delivery of primary care

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Image from Oakland Physician Network Services

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PCMH NCHA Recognition

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Who’s already a NCQA PCMH4,937 sites & 23,396 clinicians as of 10/31/2012

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ME

VT

RINJ

MD

MA

DE

NY

WA

OR

AZ

NV

WI

NM

NE

MN

KS

FL

CO

IA

NC

MIPA

OH

VAMO

HI

OK

GASC

TN

MT

KYWV

AR

LA

AL

INIL

SD

ND

TX

IDWY

UT

AK

CA

CT

NH

MS

61–200 sites

21–60 sites

0 sites

1–20 sites

201+ sites

Source: Analysis by the National Committee for Quality Assurance, Oct. 2012

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NCQA PCMH Standards 2011

Core Components• Enhance Access and

Continuity• Identify and Manage

Patient Populations• Plan and Manage Care• Provide Self-Care and

Community Support• Track and Coordinate

Care• Measure and Improve

Performance

Must Pass Components• Access during office

hours• Use data for population

management• Care management• Support self-care process• Track referrals and follow-

up• Implement continuous

quality improvement

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