Ohio Health Quality Improvement Plan
Ohio Health Quality Improvement Plan Ohio Health Quality Improvement Plan
Pa t ie n t Centered Me d ic a l Ho m e sPromote the use of the Patient-Centered Medical Home (PCMH) approach to supportthe delivery of comprehensive primary care for children, youth and adults.Through collaboration at both the state and regional levels, develop the informational, technological and reimbursementinfrastructure needed to implement and support widespread dissemination of the PCMH approach throughout Ohio.Defining the PCMH*The following definition should be used to advance the PCMH approach in Ohio. The PCMH in Ohio should provide thefollowing to its patients:• A continuous relationship with a physician or other credentialed clinician;• A multidisciplinary team that is collectively responsible for providing for a patient’s longitudinal health needs andmaking appropriate referrals to other providers;• Coordination and integration with other providers, as well as public health and other community services, supportedby health information technology;• The patient as a partner in decision-making about health care;• An expanded focus on quality and safety;• Enhanced access through extended hours, open scheduling, and/or e-mail or phone visits; and• Culturally competent care.This definition is consistent with the Joint Principles describing the characteristics of a PCMH developed by the AmericanAcademy of Pediatrics, American Academy of Family Physicians, American College of Physicians and AmericanOsteopathic Association; the PCMH minimum capabilities identified by the Medicare Payment Advisory Committee(MedPAC); and the PPC®-PCMHTM standards established by the NCQA.* The term PCMH is being used because of its widespread visibility, including in federal law, even though other termsmay be more encompassing/descriptive.Benefits and Outcomes• The Medical Home initiative at Geisinger Health Systems in Pennsylvania cut hospital admissions by 20 percent andcosts by 7 percent. 2• The North Carolina Chronic Disease Management collaborative produced cost savings of $957,493 for a sample of2,745 patients through the use of chronic disease registries. 3• The report, Financing the New Model of Family Medicine (2004), estimated that if every American had a medicalhome, health care costs would likely decrease by 5.6 percent, resulting in national savings of $67 billion per year, withan improvement in the quality of the health care provided. 4• Research conducted by RAND and the University of California at Berkeley found that care provided according toPCMH principles produced the following results: patients with diabetes had significant reductions in cardiovascularrisk; CHF patients had 35% fewer hospital days; and asthma and diabetes patients were more likely to receiveappropriate therapy. 5• The Commonwealth Fund found that a Medical Home can reduce or even eliminate racial and ethnic disparities inaccess and quality for insured persons. 62 Fox M., “Medical Home” plan cut hospital admission: study,” Reuters, September 10, 2008.3 North Carolina Department of Health and Human Services, North Carolina Chronic Disease Management Collaborative, June 2006.4 Spann S. J. et al, “Report on Financing the New Model of Family Medicine, ” Annals of Family Medicine, Vol. 2, Supplement 3, November/December 2004.5 A Robert Wood Johnson-funded evaluation of the effectiveness of the Chronic Care Model and the IHI Breakthrough Series Collaborative in improvingclinical outcomes and patient satisfaction with care, accessed January 15, 2009 at http://www.rand.org/health/projects/icice/index.html.6 Beal A. C., Doty M. M., Hernandez S. E., Shea K. K., and Davis K., Closing the Divide: How Medical Homes Promote Equity in Health Care: Results FromThe Commonwealth Fund 2006 Health Care Quality Survey, The Commonwealth Fund, June 2007 .8
Pa t ie n t Centered Me d ic a l Ho m e sTacticsPCMH Task ForceCreate a PCMH Task Force under the newly created Health Care Coverage and Quality Council (HCCQC). The TaskForce should include consumers, policymakers, educators, practitioners, payers and providers, and have co-chairs fromthe public and private sectors. The PCMH Task Force should play statewide leadership roles in the following areas:Education• Promote the PCMH approach as an effective tool for improving health care access, quality and efficiency througheducation of Ohio policymakers and the general public.• Convene institutions and associations in Ohio, at both the state and local levels, to establish learning and sharingopportunities on the PCMH approach (i.e. learning collaborative) and provide technical assistance to primary carepractices (e.g., Improving Performance in Practice, TransforMED, Institute for Health care Improvement) interestedin implementing the PCMH approach and using Health Information Technology (HIT) to transform their clinical andbusiness practices.• In coordination with the Patient and Public Involvement Task Force develop culturally competent messages, materialsand curriculums that can be used to teach patients/caregivers how to use the PCMH and self-manage chronicconditions. For some populations consideration should be given to programs that educate the patient within thePCMH.Communication and Coordination• Serve as a technical resource to keep track of federal PCMH developments and best practices in other states andcommunities, and share that information with Ohio-based PCMH advocates and program initiators.• Serve as the conduit to the federal government and national associations on PCMH issues and initiatives.• Promote coordination and linkages with other non-primary-care, health-related systems and long-term care systems tomeet the needs of individuals as they move across care settings (e.g., hospitals, home care, long-term care facilities,hospices), including:◦◦ Behavioral health systems to meet the needs of individuals with severe mental illness and/or addiction◦◦ Public health and community aging resources, and long-term services and supports (e.g., education, immunizationprograms, chronic disease management programs) to activate and support patients◦◦ Pharmacy, including making e-prescribing and Medication Therapy Management available to support the needs ofpatients, especially those with chronic conditionsFacilitation• Operationalize the PCMH definition, including, if necessary, adopting specific criteria (e.g., NCQA) for each elementof the definition for credentialing, certification and reimbursement purposes.• Promote and support local/regional PCMH initiatives and collaborations. Especially those that focus on reducinghospital readmissions through coordination between hospitals and PCMHs and invest savings into expanding accessto care.• Track PCMH initiatives and outcomes across the state.• Encourage access to the PCMH approach to people regardless of racial, ethnic, geographical and economicdifferences, through implementation in community health centers, through mobile units or other means to reachpeople in medically underserved areas and at-risk populations.• Support regional and multi-payer collaboratives to address perceived barriers, such as anti-trust issues.Evaluation• Identify and use standardized financial and clinical metrics vetted by creditable organizations to measure return oninvestment (e.g., cost avoidance and savings) of the PCMH approach (including patient safety and preventable errorrates); quality of care provided through the PCMH; and ability of the PCMH to reduce health disparities, expandaccess to care, and improve outcomes among at-risk populations.• Promote, facilitate and support the use of medical registries (e.g., American Osteopathic Association’s ClinicalAssessment Program) and Electronic Medical Records (EMR) to provide practitioners information aboutdemographics (e.g., race, ethnicity), outcomes and utilization of appropriate care processes in their patientpopulations.9
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- Page 45: CORE PLANNING TEAMAmy Rohling McGee
Pa t ie n t Centered Me d ic a l Ho m e sPromote the use of the Patient-Centered Medical Home (PCMH) approach to supportthe delivery of comprehensive primary care for children, youth and adults.Through collaboration at both the state and regional levels, develop the informational, technological and reimbursementinfrastructure needed to implement and support widespread dissemination of the PCMH approach throughout <strong>Ohio</strong>.Defining the PCMH*The following definition should be used to advance the PCMH approach in <strong>Ohio</strong>. The PCMH in <strong>Ohio</strong> should provide thefollowing to its patients:• A continuous relationship with a physician or other credentialed clinician;• A multidisciplinary team that is collectively responsible for providing for a patient’s longitudinal health needs andmaking appropriate referrals to other providers;• Coordination and integration with other providers, as well as public health and other community services, supportedby health information technology;• The patient as a partner in decision-making about health care;• An expanded focus on quality and safety;• Enhanced access through extended hours, open scheduling, and/or e-mail or phone visits; and• Culturally competent care.This definition is consistent with the Joint Principles describing the characteristics of a PCMH developed by the AmericanAcademy of Pediatrics, American Academy of Family Physicians, American College of Physicians and AmericanOsteopathic Association; the PCMH minimum capabilities identified by the Medicare Payment Advisory Committee(MedPAC); and the PPC®-PCMHTM standards established by the NCQA.* The term PCMH is being used because of its widespread visibility, including in federal law, even though other termsmay be more encompassing/descriptive.Benefits and Outcomes• The Medical Home initiative at Geisinger <strong>Health</strong> Systems in Pennsylvania cut hospital admissions by 20 percent andcosts by 7 percent. 2• The North Carolina Chronic Disease Management collaborative produced cost savings of $957,493 for a sample of2,745 patients through the use of chronic disease registries. 3• The report, Financing the New Model of Family Medicine (2004), estimated that if every American had a medicalhome, health care costs would likely decrease by 5.6 percent, resulting in national savings of $67 billion per year, withan improvement in the quality of the health care provided. 4• Research conducted by RAND and the University of California at Berkeley found that care provided according toPCMH principles produced the following results: patients with diabetes had significant reductions in cardiovascularrisk; CHF patients had 35% fewer hospital days; and asthma and diabetes patients were more likely to receiveappropriate therapy. 5• The Commonwealth Fund found that a Medical Home can reduce or even eliminate racial and ethnic disparities inaccess and quality for insured persons. 62 Fox M., “Medical Home” plan cut hospital admission: study,” Reuters, September 10, 2008.3 North Carolina Department of <strong>Health</strong> and Human Services, North Carolina Chronic Disease Management Collaborative, June 2006.4 Spann S. J. et al, “Report on Financing the New Model of Family Medicine, ” Annals of Family Medicine, Vol. 2, Supplement 3, November/December 2004.5 A Robert Wood Johnson-funded evaluation of the effectiveness of the Chronic Care Model and the IHI Breakthrough Series Collaborative in improvingclinical outcomes and patient satisfaction with care, accessed January 15, 2009 at http://www.rand.org/health/projects/icice/index.html.6 Beal A. C., Doty M. M., Hernandez S. E., Shea K. K., and Davis K., Closing the Divide: How Medical Homes Promote Equity in <strong>Health</strong> Care: Results FromThe Commonwealth Fund 2006 <strong>Health</strong> Care <strong>Quality</strong> Survey, The Commonwealth Fund, June 2007 .8
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