Guidance on intervening with panel management: hiv clinics at the forefront of pcmh models

1. Guidance on intervening with panel management: hiv clinics at the forefront of pcmh models Itta Aswad, MPH November 28th, 2012- Ryan White All Grantees Meeting

2. Disclosures This continuing education activity is managed and accredited by Professional Education Service Group. The information presented in this activity represents the opinion of the author(s) or faculty. Neither PESG, nor any accrediting organization endorses any commercial products displayed or mentioned in conjunction with this activity. Commercial Support was not received for this activity.

3. Disclosures • Itta Aswad, MPH Has no financial interest or relationships to disclose • Kathleen Clanon, MD Has no financial interest or relationships to disclose

4. Learning objectives At the conclusion of this activity, the participant will be able to: 1. Define Panel Management and describe a typical PM program. 2. Describe the association between the Patient Centered Medical Home Model and Panel Management. 3. Identify barriers and facilitators to implementing this design in their agencies

5. Obtaining CME/CE Credit If you would like to receive continuing education credit for this activity, please visit: http://www.pesgce.com/RyanWhite2012

6. HIV ACCESS is a consortium of Primary Care clinics working to provide comprehensive quality care to PLWHA The Family Care Network is a consortium of agencies that works to provide comprehensive, services across disciplines for children, youth, women and families living with HIV Who are we

7. Agenda • Overview of PCMH • What is Panel Management? • How PM works • How PM can be implemented in your clinic

8. The reality of the 15-minute visit in primary care • Only 37% of patients in one study were adequately informed about medications they were taking • 50% of patients leave office visit not understanding what the doctor said • Study of 1000 physician visits, the patient did not participate in decisions 91% of the time. Roter and Hall. Ann Rev Public Health 1989;10:163. Braddock et al. JAMA 1999;282;2313.

9. Black Hispanic White 7.0 6.0 5.0 Life Expectancy Lost (y) 4.0 3.0 2.0 1.0 0.0 Women Men Overall Racial Disparities in Survival • Late initiation or early HAART discontinuation results in life- expectancy loss • Data indicate minorities present later and have higher rates of premature discontinuation Losina E et al. 14th CROI; 2007; Los Angeles, CA. Abstract 142. Slide courtesy of Dr. William King

10. What is a PCMH? A primary care practice that has gone through an independent evaluation process, such as through the NCQA, to validate that it is able to: • Deliver comprehensive, patient-centered care • Of the whole person, • Supported by health information systems • And with accountability for results.  Slide courtesy of Dr. Kathleen Clanon

11. Key features of a PCMH include: • Enhanced Access and Open Scheduling • Adopting and Implementing Evidence Based Guidelines • Systematic, HIT based tracking of tests, results, screens, preventative therapy • Referral tracking, and follow-up • Alternate forms of patient-physician interaction (email, phone) • PCMHs are accountable for reporting on evidence-based measures of quality and patient satisfaction. Slide courtesy of Dr. Kathleen Clanon

12. Patient Centered Medical HomeImplementation Continuum Doctor and Staff Centered model PCMH Fully Integrated Slide courtesy of Dr. Kathleen Clanon 12

13. Why do we need this change? • PLWH/A are living longer • List of beneficial preventative disease activities is growing • Resources are becoming more limited • Payer models are changing (pay for performance) • Utilizing meaningful use incentives

14. What is Panel Management • Use a registry to track who needs what • Have written selection criteriato decide which patients to focus on for what • Link criteria to standing ordersfor labs, immunizations, counseling referrals, etc • Empower MA/peer teamsto take over managing routine care outside of the MD/NP visit Slide courtesy of: Barbara Ramsey, MD

15. What can Panel Management do for us? • Uncouple the Dr. visit from some of the • - Adherence counseling - Smoking cessation • - Prevention counseling - Vaccinations • - Mental Health and Substance Abuse treatment • Produce actionable interventions - phone messaging - med reconciliation

16. Pilot project- Alameda County Medical Center, Oakland CA Team Approach: • 1 Clinician • 1 Medical Assistant • 1 Registered Nurse • ~125 clients Goal: • Increase retention in care • Increase vL suppression • Increase health maintenance activities

17. Task Shifting Pre Panel Management Post Panel Management • MA- Vitals and referrals as ordered • RN- Case Management and discharge orders • MD- focus on HIV care and Primary care needs as remembered • MA- Vitals, promotes for HM tasks, referrals, in-reach to the out of care without order • RN- Case Management and discharge orders • MD- Focus on HIV and Primary care needs using support tools

18. What does Panel Management sound like? “ Hi Andre, I’m calling from Dr. J’s office. I see you are overdue for your labs. I have a lab slip for you, can you come in a see me tomorrow? Great, and we can get your flu shot done then too, and we’ll set you up to see Dr. J.” “Hello Ms. R, this is Itta calling from Dr. C’s office. How are you today? We were looking over your chart and noticed that you are coming up due for your pap smear and also your ADAP needs renewal. Is it ok if I make appts for you next week to get those done?”

19. Interventions and tools • Health messages • In-reach • Registry reports • Huddles • Decision Support sheets

20. Advantages • Proper provider assignments • Focused HIV and Primary Care tasks • Increase quality numbers • Organized care coordination • Movement toward NCQA qualification

21. Alameda County Medical Center:Panel Management At work

22. Use of a Registry Report • - How many clients in your panel? • - What information is available on each patient? • - Which patients are overdue for CD4, Viral Load, TB, Paps? • - Which patients are at goal? Which are not? • - Which patients could be prioritized for self-management support groups?

23. Exercise: Using the Registry Exercise: 15 minutes. In groups of 3-4, degsinate each person a role (MA, RN, Panel Manager, Clinician). Which clients should the Panel Manager work with first? How did you prioritize the clients? Why? What interventions would you recommend for follow-up? What is the role of other team members?

24. PM at work…the results tell all

25. Challenges and Solutions Solutions Challenges • Time • Prioritizing needs • Shifting medical practices • Scheduling protected time • Use Registry report and Decision Support tools • Communication

26. Do you have the resources to pull this off? 4 Central PM concepts • Use a registry • A team of providers willing to align resources • Prioritizing criteria • Take care out of the PCP visit when possible

27. DISCUSSION

28. Next Steps….. • Identify staff • Determine PM activities • Carve out protected time with PCP • Celebrate successes • Learning opportunities

29. Resources • Itta Aswad, MPH- iaswad@acmedctr.org • Kathleen Clanon, MD- kclanon-jba@cht.org • William King, MD, JD- wdking37@yahoo.com • Barbara Ramsey, MD- bramsey@chcnetwork.org