Patient Profile

Patient Centered Medical Homes: The Next Wave of HCV Care

The Patient Centered Medical Home is a model of care that is ideal for patients with HIV and hepatitis C virus. Although you may not be familiar with or think your practice is a patient-centered medical home, or PCMH, many HIV practices or clinics providing HIV care — and, in turn, HCV care — have developed a medical home model through Ryan White Care Act funding.

Over the last several years of health care reform, public and commercial payers as well as state and national regulatory agencies have focused on the development of PCMHs, with technical assistance resources and new payments available to help incentivize and support this model of care. For HIV/HCV providers, becoming a PCMH is a win-win situation — improved, patient-centered, coordinated care for patients, and access to additional resources for care delivery. Also, PCMH practices will be better prepared for the changing landscape of health care delivery that includes new, value-based payments and care delivery models, such as Accountable Care Organizations.

Background: The PCMH

In 2007, the primary care professional societies put forth the joint principles of the PCMH to better define the term: a personal physician, whole person orientation, coordinated care, quality and safety, enhanced access and appropriate payment.

The PCMH provides care with a focus on the whole individual, which is comprehensive and proactive, not just visit-based or dependent on patient attendance. The unit of care delivery is the multidisciplinary team that may include team members, which you see on the left in Figure 1 on page 23. Evidence-based guidelines are operationalized in the care of individuals and populations. Care is coordinated across settings, including primary and specialty care, which is particularly important for patients with HIV/HCV; in the PCMH, intensive care management that involves the development and implementation of integrated care plans is provided to a more complex, high-risk subset of the population served.

PCMHs and Behavioral Health Integration

As PCMHs have been implemented over the last 7 years, the importance of integrating behavioral health and primary care has been a key lesson learned. Behavioral health care is used here as an umbrella term that includes care related to mental health and unhealthy substance use and also involves the support for behavior change to improve health and the management of chronic conditions. Whole person, patient-centered care cannot be achieved without addressing the physical, emotional, mental and social needs of patients.

Thus, in 2014, an enhanced interpretation of the joint principles of the PMCH was put forth by the family medicine professional societies to emphasize the importance of integrating behavioral health. This expanded definition of a PCMH is one where care is delivered by a team that includes behavioral health providers. The models for behavioral health integration span a continuum that begins with coordinated care among behavioral health and primary care providers who have formalized agreements that delineate expectations for access to care, coordination and communication. The next level of integration is co-location of primary care and behavioral health in the same practice, with access to each by referral. In the fully integrated care model, behavioral health clinicians are embedded in the primary care team. In this expanded interpretation of the PCMH, care is well coordinated and communicated across physical and behavioral care, and includes shared problem and medication lists at a minimum. There is a partnership between the patient, family, physician and team, including behavioral health clinicians, with secure and confidential sharing of health information. There is enhanced access to behavioral health care, beginning with screening for behavioral health conditions/issues in primary care, and through clearly articulated communication and access relationships between partnering primary care and behavioral health providers that allow for warm hand offs, care on the same day if needed, and the right care at the right time. Last, the payment system acknowledges the importance of behavioral health intervention and incentivizes it. Rather than carving out behavioral health and placing it in a separate funding stream, funding for behavioral health and primary care is pooled and flexible.

Incentivizing the PCMH

New value based payment models are being used to incentivize and support new care delivery models, such as the PCMH. A continuum of payment models that moves progressively to more value-based payments begins with the current state — fee for service. Fee for service incentivizes the delivery of more services that are not necessarily coordinated. Along the continuum, which increasingly incentivizes quality of care and cost reductions, are prospective payments for care management, bundled payments for episodes of care for example, and global payments. These new payments might be used to pay for additional staff that are members of the multidisciplinary team, such as care coordinators, high-risk care managers, community health workers and behavioral health clinicians.

Other approaches to incentivize value are: bonuses for high quality performance on clinical, efficiency and patient experience measures; with these, metrics and measurement are the challenges. An additional approach is shared savings: providers who meet quality benchmarks are eligible to share in savings, if there are savings on total cost of care. CMS is moving to these alternative payment models, with a timeline of 30% of provider payments as alternative payment models by 2016 and 50% by 2018.

PCMH: Evidence of Efficacy

In a 2013 systematic review of the evidence base for PCMHs, it was concluded that moderately strong evidence suggests a small positive effect on patient experiences and a small to moderate effect on preventive care services and staff experiences. However, overall current evidence was deemed insufficient to determine effects on clinical and most economic outcomes. More recent PCMH evaluations in Pennsylvania and Vermont, for example, have shown improved performance on quality metrics and decreased utilization/costs of care for PCMH vs. comparison practices. In another study, there was a significant decrease in total cost of care for patients in high-risk groups who were cared for in PCMHs vs. comparison practices, but no significant differences were scene in the total population.

Changes in practice and the resultant outcomes, which can yield a return on investment, take time. Evaluations are often limited by being too short in duration, lacking clear standards for PCMHs, using varying payment models and often, lacking a good control group. Over the next several years, there should be more evidence on PCMH efficacy as there are large national demonstrations being evaluated.

Application to HIV/HCV

HIV/HCV patients are complex, both medically and psychosocially. Thus, a PCMH with proactive care delivered by a multidisciplinary care team works well for HIV/HCV patients. The care team might include the primary care provider, nurse and medical assistant; infectious disease or HIV/HCV specialist; behavioral health clinician; and a high-risk care manager. Other team members might include a clinical pharmacist, community health worker, oral health provider and addictions specialist.

Specialty Care and the HIV/HCV PCMH

Access to and coordination with specialty care is a particularly important issue for high-quality HIV and HCV care. For rural and underserved communities, an innovative approach to accessing specialists is through telemedicine. Of note, a majority of state Medicaid programs reimburse for some sort of telemedicine, including live video conferencing, remote patient monitoring and/or services delivered through store-and-forward technologies.

 

Project ECHO (Extension for Community Healthcare Outcomes) is a great example of specialty care telemedicine. It seeks to standardize care, provide access to specialty care for rural and underserved patients, magnify the reach of medical knowledge and train PCPs in specialty areas by providing continuing medical education. Project ECHO was initially focused on HCV treatment in New Mexico. A TeleECHO Clinic was implemented where the PCP would meet virtually with the HCV specialist, review cases, be provided a treatment protocol by the specialist and frequent virtual follow-ups would be conducted as needed to maximize a successful outcome for the patient.

Project ECHO has expanded to mentor and support rural and urban health care clinicians practicing in underserved communities and provide expertise in specialties including: chronic pain, integrated addiction and psychiatry care, HIV/AIDS, diabetes and cardiovascular care and rheumatology. It has spread to nine states, three countries, the Department of Defense and Veterans Affairs. This model should be an effective approach to reduce disparities, but the challenge of how to financially sustain the project remains.

Another approach to accessing specialists is the use of eConsults or eReferrals to request consultation from specialists electronically. Specialists review the consult request and triage the scheduling of visits. Many requests are handled through provider-to-provider consultation, specialist to PCP, freeing up access to specialists for patients with greater need and reducing wait times.

These approaches also improve communication and coordination between specialist and PCP, foster the use of consensus clinical pathways and enhance the skillset of primary care providers on the multidisciplinary team.

The Payment Model and the HIV/HCV PCMH

The payment model should reflect the complexity of HIV and HCV populations, including their increased need for behavioral health and enabling services. Payment should cover such services as: care coordination, high-risk care management and peer support services, as well as the telehealth services described previously.

An important issue for HIV/HCV care is having fair risk adjustment so payment rates are based on the true complexity of the population served. Social, demographic and behavioral factors have an impact on functional status and the onset/progression of disease and thus, the resources needed to provide effective care. These factors should be accounted for in risk adjustment models. However, current risk adjustment methods do not include indicators of social determinants of health, such as poverty, homelessness, education level and language. Also, these models tend to rely on coding of health care encounters, which often overlook behavioral health and substance use codes critical to HIV and HCV care. This makes the population served seem less complex.

Becoming a PCMH

There are several avenues by which HIV/HCV providers can become a PCMH. Practices can apply to be recognized as a PCMH by national or state-based certification bodies. For example, the National Committee on Quality Assurance, or NCQA, recognizes practices as PCMHs if they meet criteria that include six standards with 27 elements. To be eligible for NCQA PCMH recognition, practices must provide whole person care and meet other elements of the PCMH for > 75% of its patients. This means that in addition to primary care practices that provide HIV/HCV care, specialty HIV/HCV practices can also apply to be recognized, if they meet these criteria.

HIV and HCV care is often provided at federally qualified health centers (FQHCs) and according to the Bureau of Primary Health Care (BPHC), as of 2015, 61% of FQHCs have at least one site that is recognized as a PCMH. The Health Resources Services Administration (HRSA), which funds FQHCs, provides financial support and technical assistance to FQHCs toward the achievement of PCMH recognition.

HIV/HCV providers can also become involved in state Medicaid and national medical home programs. For example, another form of PCMH is the Medicaid Health Home. State Medicaid programs can apply to CMS to develop and pay for health homes for individuals with at least two chronic diseases. HIV may be one of them and some Medicaid programs include HCV as a chronic disease. These health homes focus on many of the same elements of care as the PCMH: care coordination, care management for complex patients, linkage to community resources, support for families and care takers, etc. Nineteen states have Medicaid health homes, and five include HIV and/or HCV patients.

Many state Medicaid programs are implementing PCMH demonstrations or initiatives that may include practices that provide HIV/HCV care. At the national level, there are currently three PCMH demonstrations, two from CMS and one from Veterans Affairs. Twelve states have set up programs for individuals who are under 65 years and disabled and who have both Medicaid and Medicare; patients with HIV and/or HCV may be included in this population. These programs are focused on improved care coordination and integration of services, including long-term services and supports, behavioral health and physical healthcare. Last, New York State has set up a hepatitis C demonstration project for FQHCs that uses the Chronic Care Model and Model for Improvement to improve hepatitis C care delivery and includes a learning collaborative and telemedicine for access to specialists.

Summary

Of the many reasons to become a PCMH, the most important is to do right by our patients. Although the data are not conclusive, through the PCMH, we could achieve improved patient outcomes and experience along with increased efficiency. The PCMH model offers the kind of care that we recognize is important for HIV and HCV patients. There is value to practices and patients in becoming a PCMH: improved care, increased revenue, improved practice reputation and in becoming a PCMH, practices will be better prepared to succeed in the new health care reform landscape of accountable care organizations and value-based payments. Knowing your state’s health care reform programs, and new payment models offered by public and private payers, will help practices access resources to become PCMHs.

Here are some resources that are available for practices interested in becoming PCMHs:

HRSA Accreditation and PCMH Recognition Initiative

HRSA/CDC Collaboration

Agency for Healthcare Research and Quality PCMH Resource Center

Ryan White Care Act Target Center

SAMHSA/HRSA Center for Integrated Health Solutions.

The Patient Centered Medical Home is a model of care that is ideal for patients with HIV and hepatitis C virus. Although you may not be familiar with or think your practice is a patient-centered medical home, or PCMH, many HIV practices or clinics providing HIV care — and, in turn, HCV care — have developed a medical home model through Ryan White Care Act funding.

Over the last several years of health care reform, public and commercial payers as well as state and national regulatory agencies have focused on the development of PCMHs, with technical assistance resources and new payments available to help incentivize and support this model of care. For HIV/HCV providers, becoming a PCMH is a win-win situation — improved, patient-centered, coordinated care for patients, and access to additional resources for care delivery. Also, PCMH practices will be better prepared for the changing landscape of health care delivery that includes new, value-based payments and care delivery models, such as Accountable Care Organizations.

Background: The PCMH

In 2007, the primary care professional societies put forth the joint principles of the PCMH to better define the term: a personal physician, whole person orientation, coordinated care, quality and safety, enhanced access and appropriate payment.

The PCMH provides care with a focus on the whole individual, which is comprehensive and proactive, not just visit-based or dependent on patient attendance. The unit of care delivery is the multidisciplinary team that may include team members, which you see on the left in Figure 1 on page 23. Evidence-based guidelines are operationalized in the care of individuals and populations. Care is coordinated across settings, including primary and specialty care, which is particularly important for patients with HIV/HCV; in the PCMH, intensive care management that involves the development and implementation of integrated care plans is provided to a more complex, high-risk subset of the population served.

PCMHs and Behavioral Health Integration

As PCMHs have been implemented over the last 7 years, the importance of integrating behavioral health and primary care has been a key lesson learned. Behavioral health care is used here as an umbrella term that includes care related to mental health and unhealthy substance use and also involves the support for behavior change to improve health and the management of chronic conditions. Whole person, patient-centered care cannot be achieved without addressing the physical, emotional, mental and social needs of patients.

Thus, in 2014, an enhanced interpretation of the joint principles of the PMCH was put forth by the family medicine professional societies to emphasize the importance of integrating behavioral health. This expanded definition of a PCMH is one where care is delivered by a team that includes behavioral health providers. The models for behavioral health integration span a continuum that begins with coordinated care among behavioral health and primary care providers who have formalized agreements that delineate expectations for access to care, coordination and communication. The next level of integration is co-location of primary care and behavioral health in the same practice, with access to each by referral. In the fully integrated care model, behavioral health clinicians are embedded in the primary care team. In this expanded interpretation of the PCMH, care is well coordinated and communicated across physical and behavioral care, and includes shared problem and medication lists at a minimum. There is a partnership between the patient, family, physician and team, including behavioral health clinicians, with secure and confidential sharing of health information. There is enhanced access to behavioral health care, beginning with screening for behavioral health conditions/issues in primary care, and through clearly articulated communication and access relationships between partnering primary care and behavioral health providers that allow for warm hand offs, care on the same day if needed, and the right care at the right time. Last, the payment system acknowledges the importance of behavioral health intervention and incentivizes it. Rather than carving out behavioral health and placing it in a separate funding stream, funding for behavioral health and primary care is pooled and flexible.

Incentivizing the PCMH

New value based payment models are being used to incentivize and support new care delivery models, such as the PCMH. A continuum of payment models that moves progressively to more value-based payments begins with the current state — fee for service. Fee for service incentivizes the delivery of more services that are not necessarily coordinated. Along the continuum, which increasingly incentivizes quality of care and cost reductions, are prospective payments for care management, bundled payments for episodes of care for example, and global payments. These new payments might be used to pay for additional staff that are members of the multidisciplinary team, such as care coordinators, high-risk care managers, community health workers and behavioral health clinicians.

Other approaches to incentivize value are: bonuses for high quality performance on clinical, efficiency and patient experience measures; with these, metrics and measurement are the challenges. An additional approach is shared savings: providers who meet quality benchmarks are eligible to share in savings, if there are savings on total cost of care. CMS is moving to these alternative payment models, with a timeline of 30% of provider payments as alternative payment models by 2016 and 50% by 2018.

PAGE BREAK

PCMH: Evidence of Efficacy

In a 2013 systematic review of the evidence base for PCMHs, it was concluded that moderately strong evidence suggests a small positive effect on patient experiences and a small to moderate effect on preventive care services and staff experiences. However, overall current evidence was deemed insufficient to determine effects on clinical and most economic outcomes. More recent PCMH evaluations in Pennsylvania and Vermont, for example, have shown improved performance on quality metrics and decreased utilization/costs of care for PCMH vs. comparison practices. In another study, there was a significant decrease in total cost of care for patients in high-risk groups who were cared for in PCMHs vs. comparison practices, but no significant differences were scene in the total population.

Changes in practice and the resultant outcomes, which can yield a return on investment, take time. Evaluations are often limited by being too short in duration, lacking clear standards for PCMHs, using varying payment models and often, lacking a good control group. Over the next several years, there should be more evidence on PCMH efficacy as there are large national demonstrations being evaluated.

Application to HIV/HCV

HIV/HCV patients are complex, both medically and psychosocially. Thus, a PCMH with proactive care delivered by a multidisciplinary care team works well for HIV/HCV patients. The care team might include the primary care provider, nurse and medical assistant; infectious disease or HIV/HCV specialist; behavioral health clinician; and a high-risk care manager. Other team members might include a clinical pharmacist, community health worker, oral health provider and addictions specialist.

Specialty Care and the HIV/HCV PCMH

Access to and coordination with specialty care is a particularly important issue for high-quality HIV and HCV care. For rural and underserved communities, an innovative approach to accessing specialists is through telemedicine. Of note, a majority of state Medicaid programs reimburse for some sort of telemedicine, including live video conferencing, remote patient monitoring and/or services delivered through store-and-forward technologies.

 

Project ECHO (Extension for Community Healthcare Outcomes) is a great example of specialty care telemedicine. It seeks to standardize care, provide access to specialty care for rural and underserved patients, magnify the reach of medical knowledge and train PCPs in specialty areas by providing continuing medical education. Project ECHO was initially focused on HCV treatment in New Mexico. A TeleECHO Clinic was implemented where the PCP would meet virtually with the HCV specialist, review cases, be provided a treatment protocol by the specialist and frequent virtual follow-ups would be conducted as needed to maximize a successful outcome for the patient.

Project ECHO has expanded to mentor and support rural and urban health care clinicians practicing in underserved communities and provide expertise in specialties including: chronic pain, integrated addiction and psychiatry care, HIV/AIDS, diabetes and cardiovascular care and rheumatology. It has spread to nine states, three countries, the Department of Defense and Veterans Affairs. This model should be an effective approach to reduce disparities, but the challenge of how to financially sustain the project remains.

Another approach to accessing specialists is the use of eConsults or eReferrals to request consultation from specialists electronically. Specialists review the consult request and triage the scheduling of visits. Many requests are handled through provider-to-provider consultation, specialist to PCP, freeing up access to specialists for patients with greater need and reducing wait times.

These approaches also improve communication and coordination between specialist and PCP, foster the use of consensus clinical pathways and enhance the skillset of primary care providers on the multidisciplinary team.

The Payment Model and the HIV/HCV PCMH

The payment model should reflect the complexity of HIV and HCV populations, including their increased need for behavioral health and enabling services. Payment should cover such services as: care coordination, high-risk care management and peer support services, as well as the telehealth services described previously.

An important issue for HIV/HCV care is having fair risk adjustment so payment rates are based on the true complexity of the population served. Social, demographic and behavioral factors have an impact on functional status and the onset/progression of disease and thus, the resources needed to provide effective care. These factors should be accounted for in risk adjustment models. However, current risk adjustment methods do not include indicators of social determinants of health, such as poverty, homelessness, education level and language. Also, these models tend to rely on coding of health care encounters, which often overlook behavioral health and substance use codes critical to HIV and HCV care. This makes the population served seem less complex.

PAGE BREAK

Becoming a PCMH

There are several avenues by which HIV/HCV providers can become a PCMH. Practices can apply to be recognized as a PCMH by national or state-based certification bodies. For example, the National Committee on Quality Assurance, or NCQA, recognizes practices as PCMHs if they meet criteria that include six standards with 27 elements. To be eligible for NCQA PCMH recognition, practices must provide whole person care and meet other elements of the PCMH for > 75% of its patients. This means that in addition to primary care practices that provide HIV/HCV care, specialty HIV/HCV practices can also apply to be recognized, if they meet these criteria.

HIV and HCV care is often provided at federally qualified health centers (FQHCs) and according to the Bureau of Primary Health Care (BPHC), as of 2015, 61% of FQHCs have at least one site that is recognized as a PCMH. The Health Resources Services Administration (HRSA), which funds FQHCs, provides financial support and technical assistance to FQHCs toward the achievement of PCMH recognition.

HIV/HCV providers can also become involved in state Medicaid and national medical home programs. For example, another form of PCMH is the Medicaid Health Home. State Medicaid programs can apply to CMS to develop and pay for health homes for individuals with at least two chronic diseases. HIV may be one of them and some Medicaid programs include HCV as a chronic disease. These health homes focus on many of the same elements of care as the PCMH: care coordination, care management for complex patients, linkage to community resources, support for families and care takers, etc. Nineteen states have Medicaid health homes, and five include HIV and/or HCV patients.

Many state Medicaid programs are implementing PCMH demonstrations or initiatives that may include practices that provide HIV/HCV care. At the national level, there are currently three PCMH demonstrations, two from CMS and one from Veterans Affairs. Twelve states have set up programs for individuals who are under 65 years and disabled and who have both Medicaid and Medicare; patients with HIV and/or HCV may be included in this population. These programs are focused on improved care coordination and integration of services, including long-term services and supports, behavioral health and physical healthcare. Last, New York State has set up a hepatitis C demonstration project for FQHCs that uses the Chronic Care Model and Model for Improvement to improve hepatitis C care delivery and includes a learning collaborative and telemedicine for access to specialists.

Summary

Of the many reasons to become a PCMH, the most important is to do right by our patients. Although the data are not conclusive, through the PCMH, we could achieve improved patient outcomes and experience along with increased efficiency. The PCMH model offers the kind of care that we recognize is important for HIV and HCV patients. There is value to practices and patients in becoming a PCMH: improved care, increased revenue, improved practice reputation and in becoming a PCMH, practices will be better prepared to succeed in the new health care reform landscape of accountable care organizations and value-based payments. Knowing your state’s health care reform programs, and new payment models offered by public and private payers, will help practices access resources to become PCMHs.

Here are some resources that are available for practices interested in becoming PCMHs:

HRSA Accreditation and PCMH Recognition Initiative

HRSA/CDC Collaboration

Agency for Healthcare Research and Quality PCMH Resource Center

Ryan White Care Act Target Center

SAMHSA/HRSA Center for Integrated Health Solutions.