January/February 2014

The Virtual Medical Home — Practical Applications of Patient-Centered Medical Home Principles

By Donald J. Murphy, MD, FACP; Shannon M. Tapia, MD; Debra J. Parsons, MD, FACP; and Genie H. Pritchett, MD
Today’s Geriatric Medicine
Vol. 7 No. 1 P. 10

Geriatric and primary care practices can transform patient care at the practice level by increasing access, improving care coordination, and analyzing practice-specific data.

Geriatric and primary care practices can strive to become patient-centered medical homes (PCMH), which studies have shown can help improve health outcomes, improve both patient and provider experiences, and control costs.1 Many practices also have opted to invest significant time and money to become certified by the National Committee for Quality Assurance (NCQA).2

While these efforts have improved processes and quality outcomes provided by PCMHs, our goal is to help geriatric and primary care practices become virtual medical homes by aspiring to PCMH tenets that deliver value. A virtual medical home may be considered a primary care setting committed to transforming care at the practice level through increased access, improved care coordination, and analysis of practice-specific data yet may not be able to obtain NCQA certification based on the specific criteria in its set of standards.

Although the PCMH concept originated in pediatrics, its benefits have been incorporated into many geriatric practices over the last two decades. To provide patient-centered, coordinated, and accessible quality care to the geriatric patient is to function as a virtual medical home.

A large percentage of older adults receive their care in the context of private internal medicine or family medicine practices, federally qualified health centers, and academic centers. In these settings, the providers may have a high percentage of geriatric patients without necessarily being geriatric specialized. It may be more beneficial for some practices to become virtual medical homes without investing significant time and resources (and risking potential burnout with uncertain yield) in attempting to become NCQA certified.

We will review some of the basic elements that define the PCMH and offer practical suggestions about using these elements to become better virtual medical homes.

Basic Assumptions
Our recommendations are based on the following assumptions. First, compensation from the Centers for Medicare & Medicaid Services (CMS) is sufficient to provide core elements of a virtual medical home. We recognize that those who have chosen to practice in primary care—particularly primary care heavily weighted toward geriatric patients—already have given much to an inherently unfair system that ultimately incentivizes specialty and procedure-based care. That said, there is enough money in the system to cover the overhead and provide attractive compensation for primary care providers both in large and small practices.

Second, all practices hoping to stabilize or grow need to embrace team-based care. All team members (eg, front desk staff, medical assistants, triage, care managers, providers) have the potential to assure patients that they indeed have an effective, welcoming medical home.

Third, well-coordinated care with efficient and creative use of provider time is the key to providing a successful virtual medical home. Finally, patients and providers must adjust their expectations as providers find ways to provide medical homes, whether virtual or NCQA certified, for the expanding Medicaid and Medicare populations.

Setting Priorities
The following are six must-pass elements of the NCQA PCMH,3 beginning with practices that are most feasible to adopt.

• Provide timely access during office hours. This element requires your office to have a process for improved patient access, including same-day appointments and timely clinical advice. Many practices assume they cannot allow open appointments in the provider schedules; they cannot afford providers’ downtime if appointments are not filled. Further, many providers are compensated based primarily, if not exclusively, on patient volume. Some providers may not want open slots, though it’s important to recognize that some unscheduled time allows for opportunities to catch up with phone calls, e-mails, charting, etc.

Open appointments, even when not filled by walk-ins, do not need to result in a financial loss for the practice. In a private practice fee-for-service model, providers can spend more time with patients scheduled before and after an open appointment if the appointment is not filled. This unexpected extra time leads to better patient and provider satisfaction. The key is for providers to know how to document and bill based on face-to-face patient time. The CMS pays fairly for the time spent with patients, but physicians must know how to capture that time.

In federally qualified health centers, the CMS pays the practice the same lump sum for each patient visit whether a provider spends 10 minutes or 70 minutes with the patient. The lump sum covers additional services such as consultation with a social worker and/or pharmacist. In these centers, providers cannot capture lost revenue from unfilled appointments by spending more time with the patients before and after open appointments. Nevertheless, the unexpected “breathing space” will lead to greater patient and provider satisfaction, and it can give providers more time to focus on other elements necessary to the virtual medical home.

An unfilled open appointment in an academic center provides an opportunity to teach students, residents, and fellows about time management, an increasingly important part of a primary care curriculum. In some cases, the academic practice can bill at an appropriate and higher level because the attending physician can see the patient with a trainee.

• Manage care for three important health issues. Regardless of practice setting, good geriatric care must focus on medication lists, including reducing high-risk medications; functional assessment; and overall goals of care, specifically advance directives. Maintaining up-to-date medication lists presents a challenge for all practices, particularly those focusing on elders who are more likely to move through the continuum of care and have medication changes along the way.

In the fee-for-service model, a medication review counts as a full past medical history when providers are billing based on evaluation/management criteria (in contrast to time-based billing). In many federally qualified health centers and academic centers, patients and providers have access to pharmacists to help with medication updates.

Obtaining good functional assessments, discussing overall goals of care, and providing good advance directives often takes more time than busy providers have when they routinely see patients every 20 minutes. In the fee-for-service model, providers can learn how to use the extra time and bill based on time. In the federally qualified health centers and academic centers, providers can learn how to focus on one or two issues, such as functional assessment and advance directives, and provide better counseling and plans for patients. The lump sum for the federally qualified health centers provides fair compensation for these professional services.

A key to narrowing the focus, however, lies in adjusting patient and provider expectations. It is a move from superficially addressing the six chronic conditions and maybe one or two new complaints in a 20- to 25-minute visit to planned visits where providers address two major issues in depth. It may involve more frequent visits at first, yet well-developed care plans and care coordination can reduce the need for multiple provider visits down the road. It necessarily involves providers letting go of the natural tendency to address most or all problems in one visit and instead focusing on the few issues or chronic conditions that most impact a patient’s well-being. These adjustments may be necessary if the limited pool of primary care providers is to provide quality care to the expanding pool of patients in Medicare and Medicaid.

Furthermore, the CMS is recognizing the challenges of providing good geriatric care. The new chronic care management fee, which is scheduled to go live this year, is an effort by the CMS to reimburse providers for the necessary and time-consuming tasks of providing quality geriatric care. Interestingly, the requirements to use these G codes to bill for a chronic care management fee require that a patient have two or more chronic conditions and that the practice be, in essence, a virtual medical home. It requires that the practices have an EHR, employ midlevel providers, provide 24/7 access to chronic care management, and meet medical home status (but does not specify NCQA certification).

These new billing codes will reward those who have adopted the philosophy of the PCMH as it recognizes the inherent benefits in the medical home process for providing quality care for complicated chronic diseases.4

• Implement continuous quality improvement. Opportunities for meaningful continuous quality improvement abound for helping older adults. Consider, for example, just one of the issues noted above: reducing the use of high-risk medications. An 18% reduction in high-risk medication use among elderly patients was reported in the Group Health of Washington PCMH initiative.1 And consider a second issue: advance directives. It’s difficult to imagine any practice (even large, well-established, integrated practices such as Kaiser Permanente, PACE, or the VA) as not having a plethora of ideas to improve advance directives for the population they serve.

The key for a practice that hasn’t pursued a continuous quality improvement program is simply to start. Identify metrics that are meaningful to the practice and its patients, measure them, and make adjustments based on the data. It also is important to keep the plans simple and ensure that the practice can afford the overhead needed for the team to complete related projects.

• Track referrals and follow up. Consider patients who, following hospitalization, either return to the clinic (or home visit) or have a subacute stay before returning to the primary care team. In the fee-for-service model, the CMS now provides a bundled payment for follow-up care provided for 30 days after a patient is discharged from the hospital, long-term acute care hospital, or subacute unit. The payment is fair and creates the incentive for practices to do the extra work to track their patients through the continuum. All fee-for-service practices caring for a large number of older adults should learn how to use transitions of care management codes.

The same is true for academic practices. The federally qualified health centers cannot charge for transition of care management codes. Nevertheless, they have other compelling reasons to track their patients through the continuum. Primary care practices cannot assume their colleagues in hospitals, long-term acute care hospitals, and subacute facilities will consistently inform them about their patients’ progress and discharge plans. Practices must determine the most efficient way to track their patients through the continuum. Additionally, using care managers for transitions of care activities can be highly effective.

Tracking referrals to specialists and ensuring timely reports from those specialists are difficult and time consuming, especially for practices not connected to specialists through an EHR. However, primary care teams that accomplish this efficiently make the follow-up visits with providers easier and more productive in all settings.

• Support self-care. Improving patient self-care involves good counseling, good educational resources, good self-management tools/plans, and assessment of patients’ self-management abilities, all of which take time. Granted, nonprovider members of the team may be the ones who most efficiently and effectively help the patient support self-care. Without adequate provider involvement, however, practices run the risk of incurring greater overhead (without increasing revenues) and adversely affecting provider and patient satisfaction.

Most providers like to counsel and teach. Most patients appreciate this additional attention and education. Practices should strive to find a good balance of educating/counseling among all team members (eg, physicians, nurse practitioners, physician assistants).

Promoting self-care for elders involves developing more creative ways of using provider time. Specifically, providers must learn how to focus on fewer issues (at least for some visits), document their discussions and counseling, and obtain adequate reimbursement for these types of visits. Again, using care managers or coordinators to connect patients to resources that enhance self-management is effective.

• Use data for population management. Practices that rely on paper charts (ie, have yet to make the full transition to an EHR) still can use data to help manage their geriatric patients. They can focus on issues important to good geriatric care, such as medication updates, functional assessment, and advance directives, and tie these into continuous quality improvement projects.

Adopting EHRs
We acknowledge that paper-based practices will not qualify for CMS meaningful use criteria, chronic care management billing codes, or being an NCQA-certified PCMH. Exploring EHR options and then purchasing and maintaining a system is a massive hurdle for most primary care practices. Ideally, an EHR would allow for improved access to data and pertinent health records, improve team-based care through enhanced communication among care team members while helping providers document efficiently and clearly, and eliminate various waste within the system.

In reality, however, this has not always proven to be the case. Too often, EHRs are not user-friendly and can distract from hands-on patient care. This occurs at a time when many geriatric providers have yet to see the benefits of EHRs for the patients they serve (with the exception that notes are indeed easier to read).5 In systems that are fully integrated, such as Kaiser Permanente, PACE, and the VA, providers can appreciate the benefits more readily than providers who work in systems that are not.

Private companies own the majority of EHR systems that qualify for meaningful use and use locked proprietary code developed by software engineers. These can be expensive to purchase and maintain, and they frequently are not user-friendly for health professionals or easily integrated across systems.6

However, practices generally can afford open-source software-based EHRs, such as the VA’s VistA system, that have been designed by health care providers. For practices feeling daunted by the purchase of an EHR required to become a certified PCMH, one option is to forgo the urge to meet meaningful use criteria and invest in an economical, integrated, open-source EHR.6

In any system or setting, providers must continually ask whether an EHR truly adds value to patient care or to the practice in general. If the answer is yes, then providers should give advice on how to most efficiently document the required data. If the answer is no, then providers should advise the primary care team to forgo that documentation, allowing the entire team to stay focused on good care for elder patients.

Final Thoughts
All primary care practices face the challenge of providing high-quality, cost-effective care amid a growing physician shortage and a financially unsustainable health care system. Creative teamwork will be essential to serving the expanding Medicaid and Medicare populations.

As the NCQA continues its efforts to create more nontraditional and geriatric-tailored outcome metrics (such as function) to allow for PCMH certification, practices without resources for NCQA certification can get a head start in providing the highest quality care by transforming themselves into virtual PCMHs. These models embrace the rigorous practice of patient-centered, comprehensive, coordinated, accessible care that is committed to quality and safety. Practices can enjoy the process and be prepared to survive and perhaps even thrive in an ever-changing world of health care reform.

— Donald J. Murphy, MD, FACP, is medical director of Medicare services for Colorado Access in Denver and a practicing geriatrician.

— Shannon M. Tapia, MD, is a fellow in geriatrics at Lancaster General Hospital in Pennsylvania and a board-certified family physician.

— Debra Parsons, MD, FACP, is medical director of the Regional Care Collaborative Organization at Colorado Access and a clinical professor in the department of medicine at the University of Colorado School of Medicine. She also is a practicing internist-geriatrician.

— Genie H. Pritchett, MD, is vice president of medical services for Colorado Access and a practicing internist-geriatrician.

References
1. Nielsen M, Langner B, Zema C, Hacker T, Grundy P. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost and Quality Results, 2012. Washington, DC: Patient-Centered Primary Care Collaborative; 2012.

2. American Hospital Association Committee on Research. Patient-Centered Medical Home: AHA Research Synthesis Report. Chicago, IL: American Hospital Association; 2010.

3. Gennari A, Fedor K, Bakow E, Resnick NM. A geriatric patient-centered medical home: how to obtain NCQA certification. Cleve Clin J Med. 2012;79(5):359-366.

4. Lowes R. CMS proposes new fee for chronic care management. Medscape website. http://www.medscape.com/viewarticle/807534. July 9, 2013.

5. Friedberg MW, Chen PG, Van Busum KR, et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: RAND Corporation; 2013.

6. Open-source medicine. In: Longman P. Best Care Anywhere: Why VA Health Care Would Work Better for Everyone. 3rd ed. San Francisco, CA: Berrett-Koehler; 2012:111-123.