Patient Centered Medical Home Initiative

The Patient Centered Medical Home (PCMH) Initiative is an ongoing quality improvement project of the Safety Net Clinic Coalition of Santa Cruz County (SNCC). The PCMH Initiative follows the IHI Breakthrough Series model for improvement which includes learning sessions, monthly webinars and direct clinic team coaching facilitated by HIP staff and outside experts. Ten SNCC clinics have established quality improvement teams that work to strengthen their clinic's capacity to provide medical homes through individualized improvement projects.

The PCMH Initiative strives to implement the following components of the PCMH model of care within SNCC clinics:

1. Empanelment: linking patients to a provider or care team.
2. Team-Based Care: care teams within clinics work together to provide quality care to all patients.
3. Patient Centered Care: patients are encouraged to take an active role in their care and treatment.
4. Enhanced Access: structuring clinic hours to reflect appointment demand, offering same day appointments, and performing chronic and preventative services at every visit.
5. Care Coordination: integrating behavioral health, specialty care and primary care services and partnering with community resources.
6. Effective Leadership: providing visible and sustained leadership committed to supporting a culture of quality improvement; providing resources for teams to implement appropriate practice changesl; and redesigning compensation.
7. Quality Improvement: training staff in quality improvement methods, using data to track progress of improvement projects and altering projects as necessary.
8. Organized, Evidence-Based Care: utilizing evidence-based care processes throughout patient care in a standardized manner.

PCMH components adopted from the Qualis Safety Net Patient Centered Medical Home Initiative (http://qhmedicalhome.org/safety-net/about.cfm).

The PCMH Initiative reaches a broader audience of providers and fosters cross-sector relationships by offering Continuing Medical Education programs on integrating behavioral health and primary care and establishing a PCMH.

Faculty for the 2011 PCMH Initiative were Eleanor Littman MSN, HIP Executive Director; Barbara Palla MD, HIP Consulting Physician; and Mike Conroy MD, Quality Leader, Sutter/PAMF. Special thanks to Sutter/PAMF for supporting Dr. Conroy's time and the sharing of his expertise with the clinic teams participating in the 2011 PCMH Initiative.

PCMH Initiative Events

Learning Session 1 - May 27, 2011

Featured Speakers:
David Labby MD, PhD, CareOrgeon
Rebecca Ramsay BSN, MPH, CareOregon
Xavier Sevilla MD, FAAP, Whole Child Pediatrics, FL

In their presentation, Primary Care Renewal, David Labby MD, PhD, and Rebecca Ramsay BSN, MPH, discussed how to create a new primary care system paradigm shift from a physician centered medical system restricted by payment models to a patient centered medical system with incentive payment models that focus on population health. Labby and Ramsay described this shift as one "from historical (craft) practice to intentional, self-reflective, collective practice". Labby and Ramsay also discussed how CareOregon, a state funded Medicaid health plan, has implemented PCMH transformation projects within participating clinics and the successful outcomes of these projects. These projects include proactive outreach to patients and open access and were associated with a greater number of patients with blood pressure under control and decreased hospital stays.

In Transformation into a PCMH: The View from the Trenches, Xavier Sevilla MD presented his experiences developing a PCMH within the Whole Child Pediatrics Clinic. Sevilla also described the PMCH model as a paradigm shift in medical care including the shift from individual to population care, physician to team-based care, episodic to continuous care, episodic payment to comprehensive payment, and from clinic centered to patient centered care. Sevilla implemented enhanced access through same day appointments and decreased wait time, created care teams, a system of emailing patients and conducting outreach calls and created a registry and individualized health plans for patients with asthma in the process of PCMH transformation.

Learning Session 2 - November 18, 2011

Featured Speakers:
Wendy Bradley LPC, Southcentral Foundation, Anchorage, AK
Christopher Campbell PA, Southcentral Foundation, Anchorage, AK
Brenda Goldstein MPH, Lifelong Medical Care

The PCMH Initiative Learning Session 2 focused on integrating behavior health care and physical health care within the PCMH. Throughout this day-long learning session, clinic teams heard presentations from various experts on behavioral health integration, participated in team exercises and planning sessions, and presented the progress of their improvement projects to date.

In Achieving Behavioral Health Integration in Primary Care Transformation, Wendy Bradley LPC and Christopher Campbell PA presented various methods for integrating behavioral health and primary care. They also discussed the key elements of the behavioral health integrated model at the Southcentral Foundation and reviewed outcomes of this integrated behavioral health program. Important outcomes from this program include:

77% of Primary Care clinic staff reported increased efficiency;

88% of Primary Care clinic staff are more satisfied with their job;

A 91% increase in patient access to Behavioral Health services; and

A reduction in anti-depressants and narcotic medication and lab orders.

Brenda Goldstein MPH, the Psychosocial Services Director at Lifelong Medical Care, presented the Partners in Health: Primary Care/County Mental Health Collaboration Tool Kit, a publication of the Integrated Behavioral Health Project (IBHP) as well as the IBHP website (http://www.ibhp.org/). Goldstein reviewed and discussed how to utilize these resources.

PCMH Continuing Medical Education Events

Patient Centered Medical Home 101 - May 26, 2011

On the afternoon of May 26^th, a panel of local physicians presented and discussed their experiences with implementing and advancing PCMHs within their various practices. Each of the Patient Centered Medical Home 101 presentations focused on a component(s) of the PCMH model and their experience implementing these components.

Mike Conroy MD, Palo Alto Medical Foundation (PAMF), focused on enhanced access, team-based care and patient-centered care, which includes a patient advisor program, at PAMF.

David Simenson MD, Golden Valley Health Centers (GVHC), described empanelment at GVHCs which included disease registries for diabetes, hypertension and warfarin patients to empanel patients.

Caroline Kennedy MD, Monterey County Health Department focused on care coordination within Monterey Country community clinics by integrating primary and specialty care.

Nancy Greenstreet, Physicians Medical Group of Santa Cruz County (PMG), explained how PMG clinics see all patients within 0-2 days of request through enhanced access programs.

Richard Helmer MD, Central California Alliance for Health (CCAH), discussed how CCAH uses provider payment incentives that reward quality patient care to advance the PCMH within contracted clinics.

On the evening of May 26^th, several national experts also discussed their experiences with advancing PCMHs. Xavier Sevilla MD, FAAP, from Whole Child Pediatrics in Florida, presented his practice's transformation into a PCMH and the results of this transformation. David Labby MD, PhD and Rebecca Ramsay BSN, MPH, both from CareOregon, presented data from numerous CareOregon clinics that are transitioning towards PCMHs. These presentations detailed the positive outcomes of the PCMH model of care such as increased patient health and satisfaction, decreased patient hospital stays and decreased costs.

Integrated Mental Health Care: Improving Lives through Effective Collaboration - October 27, 2011

Featured Speaker:
Jürgen Unützer MD, MPH, MA; AIMS Center at University of Washington

Jürgen Unützer MD, MPH, MA discussed models, outcomes and the importance of integrating behavioral health and primary care in Integrated Mental Health Care: Improving Lives through Effective Collaboration. The bi-directional effects of behavioral health and physical health suggest a need for greater integration between these services. Integrating behavioral health and primary care increases access to behavioral health care, treats the 'whole patient' and ensures that patients get better. In randomized clinical trials, integrated health care systems saw improved patient satisfaction with depression care and increased effectiveness of depression care. Integrated systems are also associated with lower total health care costs. Unützer also discussed the principles of integrated health care and collaborative team approaches to care.

SBIRT Training: Performing SBIRT in the Medical Home - November 17, 2011

Featured Speaker:
Jim Winkle MPH; SBIRT Oregon Primary Care Initiative

Jim Winkle MPH presented the SBIRT method of addressing alcohol and drug use within the primary care setting in Performing SBIRT in the Medical Home. SBIRT stands for screening, brief intervention, and referral to treatment- an evidence-based, effective method to intervene in alcohol and drug misuse within the context of a primary care visit. SBIRT has been developed to be implemented into the PCMH. This training focused on enhancing provider's brief intervention skills to address patient's behavioral health issues. Implementing SBIRT has been demonstrated to result in a 10-30% reduction in alcohol consumption at 12 months, fewer hospitalizations and ER visits and cost savings.

Participating Clinic Teams and Final Presentations

Cabrillo College Student Health Center

Diabetes Health Center
Dominican Pediatric Clinic
Planned Parenthood Mar Monte Westside
Santa Cruz County Emeline Clinic
Santa Cruz County Homeless Persons Health Project
Santa Cruz County Mental Health and Substance Abuse
Santa Cruz County Watsonville Health Center
Salud Para La Gente
Santa Cruz Women's Health Center

PCMH Initiative Presentations

Learning Session 1
Labby/Ramsay
Sevilla

Learning Session 2
Bradley/Campbell
Goldstein

PCMH 101
Conroy
Simenson
Kennedy
Greenstreet
Helmer
Community TV PCMH Program

Integrated Mental Health
Unützer
Community TV Integrated Mental Health Program

SBIRT Training
Winkle