Patient-Centered Medical Home in chronic obstructive pulmonary disease

Figures & data

Figure 1 The chronic care model (CCM).

Notes: The Improving Chronic Illness Care program is supported by The Robert Wood Johnson Foundation, with direction and technical assistance provided by Group Health Cooperative of Puget Sound’s MacColl Institute for Healthcare Innovation, and its relationship to the Patient-Centered Medical Home. (A) Copyright© 1998. Effective Clinical Practice. Reproduced with permission from Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1(1):2–4.⁹ (B) Reproduced with permission from National Committee for Quality Assurance.

Figure 2 The American Academy of Family Practice model of the Patient-Centered Medical Home.

Note: Used wth permission from American Academy of Family Practice www.aafp.org/pcmh.⁴⁵

Table 1 TransforMED PCMH Principles (http://www.transformed.com/pdf/TransforMEDMedicalHomeModel-letter.pdf) and their potential applications to COPD

PCMH concepts	COPD applications
Access to care and information
Same-day appointments After-hours access coverage Accessible patient and lab information Online patient services Electronic visits Group visits	Same-day appointments and after-hours access may facilitate timely primary care of acute exacerbations Online services and electronic visits provide professional guidance for COPD self-management (particularly helpful for homebound or less-mobile patients) Group visits offer an efficient and interactive format for planned care and patient education
Practice-based services
Comprehensive care for acute and chronic conditions Prevention screening and services Ancillary therapeutic and support services Ancillary diagnostic services	Team division of labor could facilitate planned COPD care Practice-based preventive services should include smoking cessation assistance Practice-based spirometric testing can be provided by a trained PA, NP, RRT, or RN
Care management
Population management Wellness promotion Disease prevention Patient engagement and education Leverage of automated technologies	COPD patient registry could facilitate management of practice’s COPD population Patient education is key to coping with COPD
Care coordination
Community-based resources Collaborative relationships with hospitals, ERs, specialists, pharmacies, physical therapy, case management Care transition	Practices can connect COPD patients with community stop-smoking support groups, gyms, American Lung Association chapters/Better Breathers’ clubs Continuity of care needs to be maintained when patient returns to PCP after an exacerbation managed in the hospital or ER Pulmonologist referral should be arranged and coordinated when needed Parallel primary/specialty care rather than gatekeeping is the PCMH norm Referral to pulmonary rehabilitation and access to exercise after formal rehab can be coordinated by the practice
Practice-based care team
Clinician-led multidisciplinary team Shared mission and vision Effective communication Task designation by skill set NP/PA Patient participation Family involvement options	PAs and NPs can play essential roles in team care of COPD If patients wish, interested caregivers/partners/relatives may be invited to COPD group visits along with patients
Quality and safety
Evidence-based best practices Medication management Patient satisfaction feedback Clinical outcomes analysis Quality improvement Risk management Regulatory compliance	Prompts based on COPD guidelines (spirometry, immunization, long-acting bronchodilation) could be built into clinical information systems Clinical outcomes to analyze could include receipt of spirometry, exacerbation rates, and time between exacerbation-related hospital discharge and PCP follow-up
Health information technology
Electronic medical record Electronic orders and reporting Electronic prescribing Evidence-based decision support Population management registry Practice web site Patient portal	Administrative data should be checked and curated carefully before being used for clinical registry purposes! The Devon Primary Care Audit tested a COPD assessment software tool usable on electronic medical record data
Practice management
Disciplined financial management Cost-benefit decision making Revenue enhancement Optimized coding and billing Personnel/human resource management Facilities management Optimized office design/redesign Change management	Change management is particularly central to the success of a PCMH transition Proper coding facilitates reimbursement for primary care spirometry and group COPD visits Blended payment model avoids the drawbacks of major models: salary alone (disincentive to productivity), fee for service (incentive to overuse), capitation (incentive to underuse) or pay for performance (disincentive for unmeasured aspects of care)

Abbreviations: COPD, chronic obstructive pulmonary disease; ER, emergency room; NP, nurse practitioner; PA, physician assistant; PCMH, Patient-Centered Medical Home; PCP, primary care provider; RN, registered nurse; RRT, registered respiratory therapist.

Note: Used with permission from TransforMED LLC. TransforMED^SM PCMH Principles as adapted from The TransforMED Patient-Centered Model at http://www.TransforMED.com/pdf/TransforMEDMedicalHomeModel-letter.pdf and their potential applications to COPD.

Table 2 Practice components evaluated for PPC-PCMH recognition¹⁷

Domain	Must-pass element	Additional/advanced element
Access and continuity	1A documented processes to provide same-day appointments, timely clinical advice by telephone/secure email, and to document clinical advice in the medical record	1B documented processes to provide after-hours access to appointments, records, and documentable clinical advice 1C secure electronic systems for patients to access current health records, communicate with the practice, request appointments/refills/referrals 1D continuity: documented patient selection of personal clinician and preponderance of visits with that person or team 1E informing patients about PCMH role 1F assessing and meeting cultural and linguistic needs of patient population 1G practice team organization: defined roles; meetings/communications; standing orders; distribution of tasks for patient care, self-management support, population management, and communication; involving teams in quality improvement
Identifying and managing patient populations	2D using data for population management of preventive and chronic care services, patients not recently seen, and specific medications	2A electronic, structured, searchable patient information 2B electronic, structured, searchable clinical data 2C documented comprehensive health assessment: immunizations/screenings, history, advance planning, health behaviors, mental health, substance abuse, depression screening
Planning and managing care	3C care management: previsit preparation, collaborative written care plan, addressing barriers to treatment goals, visit summary, identification of patients needing additional support; follow-up with patients who miss important visits	3A implementing evidence-based guidelines for three important conditions (including one unhealthful behavior or mental health/substance abuse problem) 3B identifying high-risk or complex patients 3D managing medications: reconciliation across transitions, prescription information, response and adherence assessment 3E electronic generation and transmission of prescriptions, integrated with patient records and patient-specific interaction/allergy warnings
Providing self-care and community support	4A self-care process: education, tools, counseling; collaborative, documented self-management plan	4B community resource referrals specific to the practice population’s needs; provision or arrangement of behavioral health treatment
Tracking and coordinating care	5B referral tracking and follow-up	5A test tracking, follow-up, flagging of abnormalities, and patient notification 5C coordination with facilities/care transitions: identification and follow-up care of patients with hospitalizations/emergency visits, exchanging information with/receiving discharge summaries from hospitals; written plan for pediatric-adult care transition
Measuring and improving performance	6C implementing continuous quality improvement for care performance, patient experience, and disparity reduction	6A measures of performance: preventive and chronic or acute care, cost/utilization, disparities 6B feedback on patient/family experience 6D demonstrating continuous quality improvement by results tracked over time 6E performance reporting within the practice (individual and aggregate) and to patients or the public 6F external data reporting: ambulatory clinical quality measures to Center for Medicare/Medicaid Services, immunization data to registries, syndrome surveillance to public health agencies

Abbreviation: PPC-PCMH, Physician Practice Connections-Patient-Centered Medical Home.

Table 3 Healthcare Effectiveness Data and Information set 2011 indicators relevant to COPD care

Domain	Indicator
COPD-specific care measurements	Use of spirometry in the assessment and diagnosis of COPD
	Pharmacotherapy of acute exacerbations
	Relative resource use by COPD patients
General preventive care measurements of special importance in COPD	Medical tobacco cessation assistance
	Influenza vaccinations for patients aged
	50–64 years (reported for commercial health plans) and those 65+ years (reported for Medicare)
	Pneumonia vaccinations for patients aged 65+ years (reported for Medicare)
Medication monitoring and reconciliation	Annual monitoring of persistent medications
	Medication reconciliation after hospital discharge

Note: Data from http://www.ncqa.org/Portals/0/HEDISQM/HEDIS%202011/HEDIS%202011%20Measures.pdf.⁴⁶

WagnerEHChronic disease management: what will it take to improve care for chronic illness?Eff Clin Pract1998112410345255

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American Academy of Family PracticePatient-Centered Medical Home (PCMH) Available from: http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html. Accessed September 29, 2011.

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National Committee for Quality AssurancePCMH 2011 StandardsWashington, DCNational Committee for Quality Assurance2011

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National Committee for Quality AssuranceHEDIS 2011 Summary Table of Measures, Product Lines and Changes Available from: http://www.ncqa.org/Portals/0/HEDISQM/HEDIS%202011/HEDIS%202011%20Measures.pdf. Accessed September 29, 2011.

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