The road to success as a Patient-Centered Medical Home
The Veranda is an Albany, Georgia-based multi-specialty practice that includes mental health, women’s health, pediatrics, family medicine, endocrinology, and weight management. The practice became involved in value-based contracts about three years ago through a Blue Cross pay-for-performance program.
Although that original pay-for-performance program resulted in updated processes, the move to become a Patient-Centered Medical Home (PCMH) was still a major transition. The practice began its journey by focusing on the mandatory requirements. “We started focusing on some of the things that we didn’t currently do,” says Veranda Practice Administrator Nancy Brown. “One of those was the huddle report, where you’re tasked with looking ahead to the next-day's schedule to identify gaps in patient care that can be addressed during the patient’s next-day visit. You have to make sure your whole care team is aware of any requirements for the patient coming in. The other initial focus area was referral management.”
Developing processes that enable proactive care
The move to proactive care demands that physicians do more than attend to a patient’s needs presented during a visit. For instance, it requires their knowing that a patient coming in the next day has diabetes and has not yet had his or her annual or semi-annual eye exam. The practice must be staffed to either provide the exam during the next-day visit or schedule it for a future visit. It’s impossible for physicians to have sole responsibility for proactive care. Therefore, people, processes, and technology must adjust to support them.
“Previously,” Nancy Brown notes, “everything was dependent upon the physician to look up and initiate clinical orders. Then it became a truly more proactive approach to building a lot of clinical and decision support alerts within the practice to be able to identify patients' needs based on diagnosis, and whether or not someone has or has not met a measure.”
“For instance,” Brown continues, “if I have standing orders that every person with a diagnosis of diabetes has to have a hemoglobin A1C once a quarter or every 6 months, based on their evidence-based guidelines, it doesn’t require a physician to initiate that order. It can be initiated by my telephone staff because they are looking at a flag that’s popped up and it says that ‘this patient was flagged with diabetes; this patient has not had these things done.’ So, you are helping to close the gaps in care at the lowest level of license by having a standing order and utilizing clinical alerts.
”Now, when physicians are with patients they need only deal with issues that require physician-level consultation. They don’t have to think about regular tests and procedures required by evidence-based guidelines. They know that those will be completed due to the processes and staff put in place.
“It’s very frustrating,” Brown says, “that a lot of physician time is spent with the patient sitting in your exam room and only then do you learn that they saw somebody else and you don’t have the results of what the other practitioner ordered.” The Veranda has developed a system whereby it knows about and communicates with the patient’s entire care team. That team automatically receives copies of Veranda’s care plan for a particular patient, and vice versa.
Staffing for proactive care
PCMH status required staffing changes. Three members of The Veranda staff moved from Certified Medical Assistant status to Chronic Care Professional designation. These three employees became the practice referral management and transitional management team. Their responsibilities include monitoring both inbound and outbound referrals for the whole practice, as well as transitional care for patients moving from an emergency department or hospital setting.
To handle overall population care management, which includes inbound/outbound referral, management of chronic disease processes, closing gaps in care, and transitional care, The Veranda has added three RNs and three Chronic Care Professionals. Brown acknowledges that all of these changes have sometimes proven to be a challenge to the practice's providers. “They have concerns,” she says, “but they are still very supportive, and they have started to see what the proactive approach is doing for them.” In fact, that’s how the practice elicited buy-in — physicians were asked what barriers to care they found most frustrating. Within the proactive care model, the practice was able to address their concerns. Now, the physicians are beginning to see that the PCMH model helps both them, and their patients.
Technology hand-in-glove with PCMH requirements
The Veranda has found that its Greenway solutions can facilitate its participation in multiple value-based care programs, from PQRS to MACRA to MIPS. “You are really doing the same thing in all of them,” Brown observes. Greenway Analytics helps identify and track progress toward patient improvement goals. And of course, meeting those goals means increased reimbursement.
“At the end of 2015, 65% of our patient population with a hypertension diagnosis had the disease under control. In 2018, almost 79% of our patients are in control."
Nancy Brown, Veranda practice administrator
The practice also uses Greenway Community, a population health tool. According to Brown, “We take our major clinical areas in which we want to see improvement. Then we look at the evidence-based guidelines and develop a protocol that the physicians and care coordinators sign off on. The care coordinators then use that protocol to build within Greenway Community the care plan and goals for that population."
“We are continuously tracking on the Greenway Analytics side,” Brown continues, “and we can see the improvements. We started focusing on hypertension in 2016 and developed the protocol with that based on guidelines. At the end of 2015, 65% of our patient population with a hypertension diagnosis had the disease under control. In 2018, almost 79% of our patients are in control.
”Measures like that contribute to staff buy-in to value-based care despite the changes it requires. “Value-based care can definitely be a win/win/win,” says Brown.