 | | HIV ACCESS Team |
So Long and Thanks for All the PCMH!
The HIV ACCESS PCMH Demonstration Project officially comes to an end this month, making this the last installment of the Home Improvement Bulletin. Thank you for your readership over the past 2 years, and for being a part of the movement to transform health care as we know it. Many thanks to our funders at the California HIV/AIDS Research Program for their commitment to innovative approaches to health care for people living with HIV and AIDS. Thanks also to our statewide evaluation team at the Center for AIDS Prevention Studies. Finally, a huge thank you to our local evaluation experts at Informing Change.
This project has given our team the opportunity to work closely with the clinics that provide HIV services in Alameda County, to support them in improving the care that they provide, and to better understand the needs of the patients they serve. It has been a rewarding experience.
As part of our final Home Improvement Bulletin, we want to share excerpts from the final evaluation report, "Using a Patient-Centered Medical Home Model to Transform HIV Care: The Implementation Experience of Three Alameda County Clinics" prepared by Informing Change.
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PCMH Demonstration Project
Final Evaluation Report
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The report uses a case study format to describe the implementation process, challenges, and successes the three pilot clinics experienced during the three-year demonstration project. Reflecting on the impact the project has had on the clinics, the report says that
"[t]he PCMH Demonstration Project has contributed to positive impact that spans from clinic staff and systems to patients and the organization more broadly. This impact has occurred to different extents depending on implementation progress at each site.
Within the clinics, staff feel more engaged and satisfied with their work. As a result of task-shifting, clinic staff are taking on new and greater responsibilities (e.g., medical assistants conducting outreach), which has stimulated greater pride and energy in their work. With this new practice, staff are better able to perform to their licensure's maximum potential
and engage in functions they did not previously have the opportunity to do (e.g., nurses taking on fewer administrative tasks)...Tangible but less visible impact initiated at the clinics can impact the organization more broadly. As a result of this project, the clinics were able to institute a more systematic approach to patient-centered care that reaches beyond the clinics (e.g., referrals to specialists, monitoring comprehensive care of patients through data systems) and may not otherwise have been prioritized. Although some of the clinic sites had PCMH-related practices in place at the onset of the project, the project served as a catalyst for moving PCMH forward collectively at the clinics and serves as a model for other departments or clinics in the organization. While each clinic is now equipped with standardized reporting tools (e.g., registry reports, decision support tools) and can benefit from PCMH experts on and off-site (e.g., HIV clinic staff, PCMH Core Management Team), the larger organization can access these resources and capacities to become more patient-centered and healthcare reform-ready as well.
The report also offers considerations and recommendations for those who may be considering transformation to a Patient-Centered Medical Home model. You can read the full report here.
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PCMH Project in the News!
A collaboration between the PCMH Project and Alameda Health System resulted in a 44% drop in hospital readmissions between 2010 and 2014. The news was featured in SF Gate, California Healthline, and the UC Newsroom.
We had the opportunity to speak in depth with Delivery System Reform Incentive Program (DSRIP) Administrator
Nancy Halloran at Alameda Health System about the drop in readmissions. She said:
"Alameda Health System has had pieces of what is now called a 'patient-centered medical home' in place in the Adult Immunology Clinic for many years (e.g., social services, some care coordination). With the help of the CHRP program and also a major grant from the Gordon and Betty Moore Foundation, we were able to put in place the piece that bridges the gap between the acute care hospital and the outpatient, as well as a more structured population health management program using a health registry. We added an RN Care Coordinator who is dedicated to identifying people with HIV as soon as they are admitted. She then follows them throughout their hospital stay and afterwards keeps working with them until they are securely connected to on-going primary care and keeping up with their medical care and self-management of their condition. This is the key to preventing readmissions.
This change coincided with a wider Care Transitions Program (CTP), funded by the Moore Foundation, that was targeted to a group of patients at high risk for readmissions, including HIV, congestive heart failure, and COPD. The HIV Care Coordinator was special in that she has one foot in the HIV primary care medical home program and one in the hospital-based CTP. It was this intervention that was primarily responsible for the reduction in readmissions."
Thanks to Nancy Halloran and Alameda Health System for sharing the gains of PCMH and care coordination work in our community.
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Assistance with PCMH Applications is available for AHC/CHCN Clinics
REMINDER: Clinics planning to apply for PCMH Recognition under the NCQA 2011 PCMH Standards must purchse their survey tool by June 30, 2014 and submit their documentation by March 31, 2015. FQHCs seeking support from HRSA for NCQA PCMH application fees must submit a Notice of Intent by June 1, 2014 if they wish to apply under the 2011 Standards.
PCMH Project staff are available to assist AHC/CHCN health centers applying for NCQA PCMH Recognition. We can help you to:
- Clarify NCQA PCMH 2011 Standards and documentation requirements
- Review a selection of documents, including all Must Pass Elements, to verify they are sufficient and appropriately labeled
- Provide feedback on potential opportunities to improve your score before submission
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Reminder: East Bay HIV Update
The 27th Annual East Bay HIV Update, hosted by the East Bay AETC and Alta Bates Summit Medical Center, is scheduled for Friday, June 13th 2014.
This event is intended for staff and providers from HIV care settings throughout the East Bay. Topics include: updates on HIV testing and treatment, linkage and retention in care, mental health, chronic pain management, and much more.
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PCMH Topics: Patient Portals
Patient portals are applications that allow patients to access their health information and interact with their provider(s) using a web-based platform. Portals may include a variety of features, such as:
- Access to lab results and medical history
- Ability to schedule and change appointments
- Secure messaging with providers.
- Prescription refill requests
- Access to health education materials
- Access to benefits information
- Platform for virtual visits
With a robust patient portal, patients can access information and interact with their clinics 24-hours a day and from the comfort of their homes (or wherever they access the internet). This enhanced access is clearly in-line with the PCMH model (see NCQA PCMH 2011 Elements 1A-C). However, patient portals are a major undertaking for clinics and other health systems; each feature requires consideration of potential impacts on clinic workflow and capacity to assist patients in accessing their information online. For this reason, many clinics begin portal implementation with limited functionality (e.g., lab results, online appointments, and visit history). Furthermore, it is important to note that patient portals cannot replace the functions of in-person and phone access. Many patients, particularly at safety net institutions do not have secure internet access.
Patient portals are an important 2014 Meaningful Use deliverable, which has served as a catalyst for many health centers to begin implementation. Six of the health centers in the Alameda Health Consortium/ Community Health Center Network are in the process of implementing a patient portal. Four will be using the NextGen product, while two will use IntelliChart. All six health centers plan to go live with their patient portal or begin a pilot by the end of summer 2014.
For more information on patient portals, check out the following resources:
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Want to know more about the PCMH Project?
For more information about our program, check out our webpage.
To view past Home Improvement Bulletins and Voices from the Field videos, please visit our Communications Archive.
For more information on our grant, view California HIV/AIDS Research Program's website.
Check out our Evernote Notebook, which we've compiled to keep track of all the tools, articles, and other PCMH-related resources we've come across. For help finding a resource, or to suggest an addition to the Notebook, contact Megan Crowley.
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Contact Us:
Erin Gael Friedman, Project Director
efriedman@alamedahealthconsortium.org
Megan Crowley, Project Coordinator
mcrowley@alamedahealthconsortium.org
Dan Clanon, IT Systems Specialist
dclanon@alamedahealthconsortium.org
Lois Bailey Lindsey, HIV Program Director
llindsey@alamedahealthconsortium.org
Kathleen Clanon MD, Principal Investigator
kclanon@jba-cht.com |
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