Case Study: Population Health

That’s what Pamela Ballou-Nelson, PhD, RN, PCMH, CCE, senior consultant, MGMA Consulting, found in the far western suburbs of Illinois: Two clinic sites caring for specialized patient needs knew change was coming, but remained uncertain how to prepare for it. “They realized payment reform was a reality; they needed transformation into a new model of care,” Ballou-Nelson explains. “They had been primarily social service-oriented, and the trend from the funding point of view was to become a patient-centered medical home (PCMH), caring for the needs of the whole person.”

The clinics’ practice leaders recognized that they needed to become a National Committee for Quality Assurance (NCQA) recognized medical home. In fact, they had been attempting to do it on their own for nearly two years. It was a struggle for them to make the self-assessment objectively; to interpret all of the standards, elements and factors of NCQA; and to adopt, implement and disseminate change.

The helping hand involved an initial assessment of the current state of the two sites with a roadmap on what they would need to accomplish to reach the goal of becoming a patient-/client-centered medical home. “Integrating clinical, behavioral, mental health and community social services is what population health management is all about,” Ballou-Nelson says.

“It’s difficult to get your hands around it yourself,” she adds, “to see the practice from a cloud point of view. Clinicians and staff are not necessarily on the same page when it comes to making the transformation to a medical home.”

Because radical change was needed, Ballou-Nelson worked with the practice leaders and staff to identify how to implement that change and to take the steps to enact it. “Practices always believe they are operating in the medical home domains,” she says. “However, it’s all about producing evidence and outcomes. If you’re saying your patients are being seen two or three times a year by the care team, taking their medications, getting their lab work done and are involved in preventive testing, you better be able to prove it and see the outcomes of such efforts.”

Getting started

The starting point began with Ballou-Nelson interviewing staff members and doing a full assessment of where they were. Simultaneously she prepared a gap analysis of where they needed to be according to the NCQA PCMH standards. 

Using the assessment, a process improvement team made up of executives and other key staff from both sites was created. Team members established guiding principles and settled on the following areas to guide the medical home transformation activities. 

First, they decided that the executive steering team would make binding decisions through consensus, that most people should agree with these binding decisions and that these decisions should be choices that everyone can live with. 


 

Change is by nature disruptive, but it’s up to each practice to determine how disruptive a change it wishes to make and how quickly changes would be made. The two practices decided that they were aiming for “fully disruptive,” supporting transformation of people, process and technology. 

The technology is another critical area to manage. Should practices use multiple tools with functional overlap or invest in a single EHR tool and repository? Both practices chose a “rationalized” implementation: complementary tools with functionally distinct repositories.


Integrating service lines and care plans appropriate to patient care is another important step to becoming a PCMH. The practices opted to optimize integration and become fully integrated when possible.

 

One of the hurdles encountered was allowing patients more input in their own care. Self-management and shared decision-making are not common approaches in the medical model of care. Assisting patient movement along the patient activation scale, which measures a patient’s ability to manage his or her own care, takes input from care managers, behavioral health professionals and medical providers. 

The office manager worked with Ballou-Nelson and the sites’ process improvement team to develop standard workflows and quick guides across the six medical home standards. “We brought the staff as well as physicians and nurse practitioners together and discovered everybody had a different idea on protocols and how to use the various fields in the EHR,” Ballou-Nelson says.

Fourteen months later, after a few stops and starts, the team is on target with its own self-imposed roadmap. EHR skills and awareness have improved. The workflows are in place. The office manager runs reports not only for PQRS and meaningful use, but also for care plan functions showing the “voice of the patient.” The office manager has secured new contracts to expand the patient base and reimbursement options. 

“They have done extremely well,” Ballou-Nelson reports. “There has been a tremendous amount of change, and the change will continue as they sustain the transformation to new levels of responsiveness. The goal to submit to NCQA July 2016 is on target."

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