Below is an article published by the American Institute of Research (AIR), detailing IHC’s PCMH efforts thus far. Many thanks to ALL of our IHC staff who have been instrumental in the PCMH process. We are proud of this accomplishment!
The Essence of PCMH In Practice
The patient-centered medical home (PCMH) model is designed to give the patient an active role in managing their health care and provide a high quality of care while reducing overall cost. Elvin Plank, Chief Executive Officer (CEO) for the Indiana Health Centers (IHC), shared a story that he feels represents the essence of this concept and the potential impact PCMH could have on a very strained health care system. A consumer member of the IHC board of directors has also been a patient at the Kokomo Health Center for the past 6 years. Prior to becoming a recipient of services at Kokomo, he had been a regular patient and a “frequent flier” in the local emergency room (ER), suffering from symptoms that seemed to get progressively worse over time. He had no health insurance, lacked resources, and felt he couldn’t afford to go anywhere else. After several ER visits precipitated by painful symptoms, the patient was diagnosed with a chronic illness affecting his immune system. “I didn’t know what this was or if I was going to live two months, eight months or another year,” the patient said. He continued to frequent the ER for episodic care, where he’d receive multiple prescriptions he couldn’t afford to fill and complex instructions which he couldn’t follow. Within a short time, he would end up back in the ER with a recurrence of symptoms, so the cycle continued.
Finally, he was referred to the Kokomo Health Center for primary care services and help with managing his illness. He made the appointment and that’s when he learned that, although his condition could not be cured, it could be managed with coordinated health care that included preventive visits with the medical team, affordable medications, and clear and simple instructions for managing his own treatment. The patient participated in the development of his plan of care with the team, learned more about his illness, including how to prevent recurrences of symptoms and ways to manage it. The team educated him on the importance of working together to manage his care. He said, “I feel so much better, they help me get my medications, and I just feel really good.”
For the past 6 years, this proud board member has been going to the Kokomo Health Center and has not returned to the ER. The cycle was broken when he became centrally involved with, and knowledgeable about, his own heath and treatment, with support from a strong team of professionals. This is the essence of the patient-centered medical home. “That personifies what we’re all about,” said Plank. “That personifies our mission.” This story has been shared many times, including on Capitol Hill, and it speaks to health care in a very personal way.
Indiana Health Centers, Inc. was founded in 1977 to provide primary health care to migrant farm workers and their families. Today IHC serves the residents of Indiana including three distinct population groups; agricultural workers in the State of Indiana; low-income residents of St. Joseph, Howard, Cass, Grant, Miami, and Jackson Counties, and the homeless population in the city of South Bend. In the 1990s, Indiana saw a decrease in the migrant worker population, which led IHC to launch a migrant van program to ensure it continued to care for those patients who depend on IHC. This complex and diverse patient population is ideally suited for a population health approach, making becoming a PCMH a logical step in IHC’s practice transformation process.
Strategies for Becoming a Patient-Centered Medical Home
Start With a Team
IHC is committed to providing high-quality patient health care and found that the Centers for Medicare & Medicaid Services (CMS) Advanced Primary Care Practice (APCP) demonstration aligned precisely with its mission and vision. The CEO joined IHC in the spring of 2013 and immediately began assembling the PCMH team. Despite starting its practice transformation efforts later than other sites, IHC was able to put together an outstanding team including the chief executive officer (CEO), chief operating officer (COO), deputy COO, chief financial officer (CFO), chief medical officer (CMO), chief compliance and quality officer (CCQO), practice managers from all of their practice sites, and other frontline team leaders. The team began rapidly working on practice transformation and was able to meet the first CMS benchmark in November 2013. IHC has maintained this level of intensity, continuing to set and meet intermediate goals; they submitted for Level 3 Recognition in early August 2014.
Most notable about IHC is its leadership team. Leadership engagement is essential to the journey to Level 3 Recognition and IHC has a strong leadership base. IHC leaders are engaged and committed champions for this transformational journey. CEO Elvin Plank believes in the work and feels that IHC is “doing the right thing for the right reason.” Engaged leaders understand that this is a team effort, and requires involvement and input from staff at every level. They ensure that there is staff involvement and feedback, noting that staff engagement mirrors that of the leadership. “The most important thing we have is this amazing group because they’re all so committed to the PCMH and the APCP demonstration process,” said Nicole Meyer, CCQO.
IHC’s commitment extends beyond the demonstration and is incorporated into the strategic and financial plans for the organization, which include key elements for long-term sustainability of the PCMH model of care. A tangible demonstration of this commitment is the profit sharing plan built on quality indicators created by CEO Plank. This plan provides rewards to staff for achievements, including meeting patient care quality goals, and serves to motivate everyone to continue to improve. Plank states that their profit-sharing plan ties quality to performance, not productivity. The team believes success is the result of the team, and it should be the team who shares in that success. The profit-sharing plan includes all staff and is based on quality indicators identified by the team. This in conjunction with the staff and leadership commitment will lead to sustainability of the progress made beyond the end of the demonstration and well into the future.
Electronic Health Record
One key to enhancing performance was training staff in the most effective use of the electronic health record (EHR). Additionally, the decision to purchase the Care Coordination Medical Record (CCMR) module, a care management tool that interfaces with the EHR, turned out to be a wise and necessary investment. CCMR improved efficiency in documentation and decreased redundancy. “We were glad when CCMR was brought on board because it satisfied several things for PCMH, so we didn’t have to repeat things in different places,” said Nurse Manager Angie Turnpaugh. It also made getting staff buy-in a little easier. “Once we explained why we wanted to do this and everyone could see the results, the providers absolutely loved it,” said Shannon Bates, practice manager for Cass and Miami counties. This module improved coordination of care and allowed the team to track progress in the EHR. Initially there were some issues with the interface for the CCMR module and the EHR. “When CCMR wasn’t working with the EHR, our IT staff spent several weeks working on the issue and preparing to go live resulting in a very successful upgrade,” said Meyer. The EHR upgrade was a major undertaking for the center and involved all staff and leadership.
Staff Engagement and Buy-In
Getting team buy-in was important. “The staff had to understand why we were doing PCMH,” Meyer said. “Convincing the staff that it was the right thing to do was critical.” Each provider had a certified medical assistant (CMA) and a team nurse who collected information and completed most of the data input, which increased productivity and also ensured staff received credit for the work done. Placing tasks with the appropriate staff member led to more efficiency in the care provided. The staff was involved with decisions related to PCMH and practice transformation and their feedback was incorporated into any changes made.
Effective and Efficient Communication
To improve communication, the sites had daily huddles, “which we’ve learned can kill 14 birds with one stone,” Turnpaugh said. The huddles improved flow of information and highlighted critical needs for the patients scheduled to be seen on a given day. The teams discussed plans to ensure patients received all needed services while in the center. The front desk staff was incorporated into the teams to ensure patient flow is maintained from the point of entry to discharge. There is a CMA responsible for completing prescreening for all teams and reviewing preventive care indicators and other pertinent information in preparation for the patient visit. This information is flagged in the EHR for the team and the issue is addressed during the visit, supporting the continuum of care.
Comprehensive and Seamless Service Coordination
IHC also strives to improve care coordination by providing a “seamless array of services,” said COO Jose Perez. If a patient is due for a particular procedure, or has never had dental services, or requires any other cross-discipline assistance, that person is literally walked from one exam room to another. “If a child comes in for any reason and it’s noted that he has never seen a dentist, we walk him right over and sit him in the dentist’s chair,” Perez said. “A warm handoff is the most effective handoff.” This “warm handoff” requires flexibility in scheduling so that the needs of the patient can be met in a timely fashion. IHC has created a patient-centered culture that facilitates this practice.
With positive patient outcomes being at the heart of the PCMH approach, “making operations and quality work together has been absolutely key,” said Plank. “We’ve only been at this for a year. Having the right people in the right place doing the job well is critical. Having quality improvement and operations working hand-in-glove means process improvement, and that moves everything forward. Our three aims are improving the health of the population, improving the patient experience, and doing all of that at lesser cost,” said Plank. For patients like the IHC board member profiled earlier, this commitment to quality care will keep him, and IHC’s other patients, coming back to the Kokomo center and the other centers that are part of the IHC.
Effective Use of Technical Assistance Resources
Among the lessons learned for IHC in terms of the APCP demonstration project is that “it required a lot of change in a short period of time,” said Meyer. IHC worked with technical assistance (TA) resources provided by the American Institutes for Research (AIR) including the AIR TA Liaison, the Indiana Primary Health Care Association (PCA) coach Carla Chance, and Susan Crocetti from Qualis Health, to tackle the goal of achieving recognition. IHC started the practice transformation well into the project timeline, noting the partnership with their Qualis Health representative and their PCA coach provided the support they needed to attempt this daunting task in a short period of time. TA included reviewing documentation, providing coaching strategies and on-demand learning resources, interpreting the National Committee for Quality Assurance (NCQA) standards, and incorporating PCMH concepts in a manner that was meaningful and in line with IHC’s overall mission of providing high-quality patient care.
Challenges and Lessons Learned
Challenging population and environment
Like all health centers, IHC operates in challenging environments. Its South Bend and Kokomo centers are the largest and least rural, while the others—in Logansport, Marion, Peru, and Seymour—serve rural areas across multiple counties, where patients must often travel long distances to seek care. There is a sizeable homeless population, a “huge number” of migrant farm workers and their families, some of whom live in camps, and a growing immigrant population. This requires IHC to find creative ways to ensure patients have access to the services they provide. IHC is committed to providing high-quality care to its patients and using resources, such as the mobile van for the migrant workers, to achieve its goal.
In terms of sustainability, “Some pressure needs to be put on increased reimbursement,” said Kokomo Site Medical Director Dr. Lenny Philip. Care management is not reimbursable, and much of the work involved with PCMH is related to care management. Funding from the APCP demonstration has supported some of the work but more funding is needed. Even when the demonstration project is over, no staff positions will be cut, included those in quality improvement, said Plank. “We’ll get grants or figure out other ways to keep patient care at the highest quality.” The team is committed to continuing the work and sustaining the gains made through other funding sources.
In summary, the initial startup of the PCMH process was very chaotic for the team, but this was improved with the use of internal resources and the AIR TA resources provided by the APCP demonstration. Leadership engagement set the stage for the team, and continued leadership support is required to stay the course. This led to staff buy-in particularly when processes and policies changed the work environment and the front line team was impacted. Supportive leadership continues to work with the team to gather its feedback and incorporate it into the changes made and ensure communication remains fluid. Finally, dedicated staff members are essential to sustainability. Positions at IHC are supported by some of the APCP incentive funds, but these positions are factored into the overall budget to ensure the work remains sustainable in the future. The major objective is to ensure that the patients see and feel the impact of the team’s efforts in the experience they have each time they enter an IHC center. IHC applied for Level 3 Recognition in August 2014 for all four sites in the demonstration.