Tuesday, June 1, 2010

An Update On Pennsylvania's Collaboratives on the Patient Centered Medical Home (PCMH)

Go to the National Committee on Quality Assurance's (NCQA) or the Patient Centered Primary Care Colloaborative's (PCPCC) web sites on the Patient Centered Medical Home (PCMH) here and here, and you'll be treated to a set of criteria, principles, guidelines, certifications and other high falutin' stuff that are well suited to policymakers, academics and administrators. All that documentation is a necessary evil that helps certify and assess PCMHs. Unfortunately, for the healthcare providers that actually take care of patients, those concepts are of less use. They need something with more substance.

The Disease Management Care Blog to their rescue, thanks to its participation today in an update on the Pennsylvania Diabetes Action Partnership. Much of this initiative is directly focused on setting up regional multi-county "collaboratives." Within each are a limited number of primary care sites that receive logistical assistance in setting up PCMHs. Depending on the support of health insurers as well as the availability of grant support, financial aid is also available. As of this posting, a total of 152 clinics are participating and each clinic is submitting outcomes data into a central Statewide registry

Now that more than a year has elapsed, it's becoming possible to use the data to assess which clinics seem to be achieving more than their fair share of success. According to today's update, visit the higher performing clinics and you will find:

Ready/short hand identification of patients and records of persons with diabetes: This may mean a sticker on the cover of a paper chart or an onscreen prompt when there is an electronic record.

Regular review of registry data for "exception" patients: It's one thing to maintain a paper or electronic registry, it's another to actually use it so that the providers can spot the patients with care lapses such as missing appointments or absent lab testing. This review can occur weekly or monthly.

Contact them: This may take a lot of time, but someone has to telephone, leave voice-mail messages, telephone again, email, text etc over and over and over to track down the exception patients with care lapses.

And bring them in: This also burns a lot of time, but many of these individuals need to be corralled into coming into the clinic for face-to-face care. These patients don't necessarily need to see a physician, but they do frequently need to see a trained health care professional.

And, most of all, get them to take care of themselves: These clinics have set up multidimensional educational interventions (from brochures in the waiting room to one-on-one sessions with nurse-educators) aimed at getting the patient to set up their own care goals and avoid having to be a future "exception" patient.

Like other sectors of the service industry, this is a high touch game won by lots of individual consumer attention. It's also a set of characteristics that seem to be largely under-recognized by the accreditation process.

There was also some interesting information on three barriers to PCMH implementation that the DMCB had not previously read or heard about until today:

1. Staff turnover is not unusual among primary care clinics, but this is now resulting in the loss of trained teamed members and the need to invest in ongoing and costly staff education.

2. Simultaneous installs of electronic health records. This makes sense, but primary care sites are being asked to institute an electronic record and start of PCMH. The level of effort is reportedly extraordinary.

3. Large multi-clinic practices are frequently run as primary care site "confederations." Just because one physician group is enthusiastic about the PCMH doesn't mean that its sister sites will be willing to redesign their practices.

Finally, there is still no definitive word on reduced claims expense and whether the Pennsylvania version of the PCMH saves money. More to follow.


Dr Synonymous said...

Helpful insights from DMCB about cumbersome aspects of setting up PCMH and how misaligned it is with much of the reality of primary care.

If the cable company took over diabetic education and baby sitting patients, the "outcomes" would soon be better than the same education and babysitting by physicians. Leveraging patients with real incentives such as winning the right to each cable channel or special channel would be a powerful incentive. Can physicians match that?

Jaan Sidorov said...

Even more ironically, people seem to have absolutely no problem paying through the nose for cable, while a we continue to fret over $5and $10 co-pays. There are lots of parallels here.... I see the seeds for a future posting......