UMass Medical School patient-centered medical home experts to present at Institute for Healthcare Improvement summit

March 17, 2016

A team of UMass Medical School experts on patient-centered medical homes will present about behavioral health integration, care transitions and developing a medical home workforce at the Institute for Healthcare Improvement summit March 20-22 at the Orlando World Center Marriott Resort & Convention Center in Orlando, Florida.

A mini-course and posters will be presented at the 17th annual International Summit on Improving Patient Care in the Office Practice & the Community. The experts are from Commonwealth Medicine, the health consulting division of UMass Medical School.

Health Equity: Linking Community and Health Systems
Noon to 5:30 p.m. March 20

This mini-course will focus on eliminating health disparities and achieving quality health care for all, using the Prevention Wellness Trust Fund project in Worcester as an example. The state-funded initiative was created to manage chronic disease, reduce health care costs and create links to home- and community-based resources. UMass Medical School is one of several partners on the project. The session will feature the approaches taken to implement an integrated model that improved linkage to and the exchange of patient information to improve chronic disease outcomes and increase access to quality care.

Sai Cherala, MD, MPH

Stories from the Front Line: PCMH Care Transitions
9:30 to 10:45 a.m. March 22

The Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI) was a three-year multi-payer demonstration designed to promote clinical model transformation in practices across the state and prepare the practices for PCMHI recognition. It was a partnership between MassHealth, the Massachusetts Medicaid program, and UMass Medical School. An analysis of the project at 46 participating practices finds that primary care practice transformation takes time; care transitions, including emergency room and post-discharge follow-up care, require the development of new clinical workflows; and the processes of care are more likely to improve before outcomes are affected. These lessons learned can aid provider organizations nationwide: focus on highest-risk patients, prioritize high-volume hospital systems for information-sharing; streamline documentation of the workflow in the electronic health record; and clearly identify the role and function of each care team member in the new process.

Joan D. Johnston, RN, PCMH CCE
Sai Cherala, MD, MPH
Ruth Aboagye, MBA
Pamela Senesac, PhD, MS
Judith Steinberg, MD, MPH

Posters will be presented March 21:

Whole Person Care: Implementing Behavioral Health Integration in the Patient-Centered Medical Home
Primary Care Payment Reform (PCPR) is an alternative payment pilot program of MassHealth, with learning collaborative support from UMass Medical School, that introduces the principles of accountable care, behavioral health integration and patient-centered medical homes in primary care practices. The pilot demonstrated that behavioral health integration is a necessary component of whole-person care and a complex, but highly accomplishable task; numerous transformation strategies can support the clinical, financial and cultural challenges to integration; and alternative payment models are essential to support sustainable, expandable and successful behavioral health services in primary care.

Judith Steinberg, MD, MPH
Joan D. Johnston, RN, PCMH CCE
Josh Twomey, PhD

Developing the Medical Home Workforce
A pro-active multidisciplinary team-based care model was developed after identifying key skills and competencies needed for a patient-centered medical home workforce. The patient-centered medical home may solve many of the ills of our health care system; new health care payment methods support care team member roles and services in patient-centered medical homes; an enhanced skill set for the entire care team is needed for successful implementation; a redesign of training and education to support existing and incoming workforce is required; and a focus on inter-professional collaborative education is needed.

Sai Cherala, MD, MPH
Judith Steinberg, MD, MPH

Primary Care and the Perioperative Surgical Home
Our team partnered with UMass Memorial Medical Center’s Urology and Anesthesiology departments on a pilot patient-centered, physician-led, multidisciplinary team-based system of coordinated care for the surgical patient. The goals were to improve the patient experience, improve health care and reduce costs. Primary care physicians were surveyed to understand how surgical teams can better coordinate care with primary care. The results of the survey show that concise, useful communication about mutual patients is important to primary care physicians; there is no need for immediate follow-up appointments with primary care physicians unless necessary – appointments are recommended for two to four weeks after discharge; and defining the roles of primary care physicians and the surgeon is important.

Valerie Konar, MBA, MEd
Judith Steinberg, MD, MPH

Using PDSAs to Optimize Cervical Screening
This poster describes a project that used a patient-centered medical home model to improve cervical cancer screening for patients at Duffy Health Center in Hyannis. Lessons learned include: identifying existing opportunities to provide whole-person care may provide revenue enhancement opportunities; practice workflow tools require user input in their development to be accepted and effective; buy-in from all team members is crucial and it is important for the team to agree on the process; and data collection is essential, along with ongoing quality improvement and practice transformation coaching.

Joan D. Johnston, RN, PCMH CCE

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