Mercy's Journey Toward Patient-Centered Medical Homes, Population Health

Two years ago, Mercy began its journey toward patient-centered medical homes by enrolling two of our physician offices in a Catholic Health Partners pilot to explore the development process of PCMHs. The pilot had positive results, so we decided to roll out the PCMH model to all 20 of our primary care practices. We set the goal that, by the end of the year, all 20 of these practices will have received or applied for Level II or III PCMH recognition by the National Committee for Quality Assurance. So far we are on target to reach this goal. We've learned a lot in our journey toward the PCMH model, and some of our key learnings may be useful to other practices and clinicians who embark on this voyage after us.

Why pursue PCMHs?

Patient-centered medical homes are being pursued by physician groups for a variety of reasons. From a strategic standpoint, PCMHs are a foundational component of a system's capability to manage population health. Beyond that, though, pursuing PCMHs is the right thing to do for patients.

Additionally, study after study has found that the PCMH model improves patient satisfaction, as well as physician and staff satisfaction. It's a win for patients; it's a win for physicians and staff; and it's a win for the healthcare system in that it changes how we treat and manage patients.

PCMH timeline

Transitioning to a PCMH doesn't happen overnight. Based on our experiences at Mercy, it generally takes 12-18 months to get a practice to a point where it could qualify for PCMH recognition.

If the practice is new to our system, the timeline is extended to 21-24 months. For example, if Mercy acquires a previously independent primary care practice, it generally takes 3-6 months to get the physicians and staff acclimated to the Mercy system — scheduling changes, payroll changes, billing changes, etc. Then, we deploy our system-wide EHR in the practice, a process that typically takes six months including set-up, training, go-live and reaching a steady state of performance. An EHR is absolutely essential for PCMHs — at least in our experience — to be able to track measures and identify patients who are in need of interventions. Also, EHR meaningful use criteria are incorporated into the NCQA standards for PCMH. After all of this, we focus on developing a practice culture of continuous improvement and population management that is critical for PCMH transformation.  

Selecting PCMH measures

From a population health standpoint, PCMHs lead to decreases in hospital admissions, hospital readmissions and inappropriate ER utilization while improving preventive health efforts. To impact these macro issues, PCMHs focus on specific measures under two umbrellas: chronic condition measures and preventive care measures. With no shortage of opportunities for potential quality improvement, to start our PCMH transformation we focused on three measures from each bucket with a goal of  "moving the needle" significantly by staying focussed. This is consistent with NCQA standards for medical home recognition. Other PCMH recognition/certification organizations, such as The Joint Commission, have similar requirements.

All family medicine and general internal medicine practices within the Mercy system agreed to focus on the same six measures. We felt doing this would help us focus on process and transformation culture while sharing best practices. If each practice had its own measures, we worried we'd spend too much time developing the measures rather than working on the transformation processes to improve them.   

The six measures we selected were (1) A1c levels less than 8 percent for patients with diabetes, (2) blood pressure below 140/90 for patients with hypertension, (3) tobacco use counseling for tobacco users, (4) breast cancer screening for women ages 40-69, (5) colorectal screening for men ages 50-75 and (6) pneumonia vaccination for men and women age 65 and older. Individual practices can expand upon these measures.

Achieving performance improvement

In order to improve our baseline performance in these areas, we needed a way to pull reports on each of these measures, by physician and by patient, which proved challenging. One option was pulling ad hoc reports, but this would have been extremely time consuming and resource intensive. Instead, we decided to install an add-on, web-based reporting tool; each night, all of the clinical data from our EHR is imported into this tool. Then, physicians or other staff members can easily pull reports on performance against each measure.

We require that physicians pull their reports at least once a month, but many select to pull these more frequently. For example, within a matter of seconds, a physician can download a list of all his or her patients with diabetes who have an A1c at 8 percent or above. Then, the physician, care manager and staff can begin to test different interventions on these patients. If one intervention doesn't lead to improvement, they try another. If one works, they will roll it out to their other patients, and if it's really working, across the entire practice. This rapid cycle improvement process is an approach to quality improvement that we want the practices to become comfortable with to the point that it becomes second nature for quality improvement and for practice operations problem solving in general.

This is really the core of our performance improvement efforts: Give each practice a "buffet" of possible interventions (ideas) and let them determine which works best for their patients and their practice. Performance improvement efforts are very practice oriented, because what works best for one practice and its patients may not work best for another.

We use this approach for dealing with both the chronic and the preventive measures. For example, patients over 50 who are due for a colonoscopy need to be contacted in some way and encouraged to undergo the procedure. For some practices, simply sending a letter to the patients' homes will be relatively successful; in other cases, calls or emails from physicians and or nurses may have better results. It's all about trying different interventions and rapidly changing processes once we find something that works.

Hardwiring new processes

While intervening when patients fall behind on their care is critical, perhaps an even more important role of the PCMH is to keep healthy patients healthy and chronic conditions managed. This responsibility is fulfilled by ensuring patient visits are comprehensive and counseling patients on healthy behaviors when appropriate.

For example, for every diabetic patient a physician sees, there are about 20 different evaluations or tests that must be routinely carried out for NCQA certification. Examples include the A1c test, cholesterol test, eye exam, foot exam and tobacco use counseling, just to name a few. Before we began the journey to become a medical home, our medical assistants, nurses and physicians were routinely fulfilling about 10 of these 20 requirements; the challenge was then how to hardwire performing the 10 that were sometimes missed or were not satisfactorily documented.  

The answer for us was the concept of the "planned visit." The planned visit is our effort to improve our processes around a patient's visit to ensure that we are completing all required evaluation steps for each patient with a chronic condition. Our physicians and staff developed a checklist for each planned visit to ensure that no steps are skipped. Then, this checklist was imported into a template in our EHR system that is used by our medical assistants and physicians every time they treat a patient with one of the three chronic conditions we have targeted.

Each template has three sub-templates. The first guides the medical assistant in the collection of data and allows them to record the results of all measures and tests directly into the EHR. The second guides the physician or medical assistant in giving the patient instructions about his or her condition and treatment, and the third guides the physician in setting specific goals with the patient for healthy behaviors.

This third component is really critical, because it's difficult for a PCMH to improve the health of its patients without the patients playing an active role. During goal setting, the physician and staff help the patient set a specific and realistic behavioral goal. So, for example, if a diabetic patient drinks an average of three sodas per day, the physician may ask the patient if he or she could reduce that to one soda per day or change to diet soda. If the patient agrees that this is possible, the physician or staff member asks about barriers to achieving this goal and helps the patient identify ways to overcome these barriers. The physician also inquires about the patient's confidence in meeting the goal. Once the goal is agreed upon, a date to achieve the goal is set, the goal is entered into the template and the patient receives a copy of what is essentially an agreement for change. While this may seem like a lot of effort to achieve a small change, counseling for healthy behaviors and documenting a patient's promise of improvement helps ensure that small change is achieved. Even though it's small, it's better than no change at all, which often happens when goals are not patient-specific and/or too broad or numerous.

Healthier patients

At Mercy, our hope is that by doing all of the things I've described here — from measurement, to interventions, to planned visits and goal setting — we will be able to move our measures and improve the overall health of our patients. By the time all of our practices achieve PCMH recognition we believe they will have significantly improved performance on the six measures selected for this year. We are seeing significant improvements within six months of implementation of the measurement tools.

Next year, the practices will have to opportunity to add a fourth chronic measure, and we also plan to begin implementation of embedded care coordination teams within each practice to continue to move the needle toward healthier patients.

We believe that our journey toward PCMH recognition will help improve the health, and the lives, of our patients because the model provides more comprehensive, coordinated and engaged care to them and with them! While it may seem the PCMH recognition is our end goal, that's not the case at all. Our goal is to achieve true and sustainable practice transformation. To me, that means much more than any piece of paper and that has always been the reason behind the significant time, resources and effort we have put into transforming our primary care practices into medical homes.

Kenneth Bertka, MD, is a family physician and vice president of physician clinical integration at Mercy, a seven hospital and physician group system based in Toledo, Ohio. Mercy is a member of Catholic Health Partners, the largest healthcare system in Ohio.

More Articles by Dr. Kenneth Bertka:

Patient Engagement's Critical Role in Post-Reform Success: 6 Steps to Improve Patient Centeredness
Using HIT to Drive Clinical Integration, Patient and Physician Engagement and Population Health Management
Hospitals and Patient Centered Medical Homes: A Practical Pairing

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