GBMC's Patient-Centered Medical Home Foundation
This information discusses the foundation of GBMC's Patient-Centered Medical Home, highlighting its system of care, healthcare services, care management focus, accountable care, and population health activities. It also covers post-hospital follow-up visits, care team impact on quality metrics, and the importance of coordinated care.
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GBMCs Patient Centered Medical Home: The foundation to building a System of Care Danielle DaSilva, MHA Ambulatory Service Line Administrator June 2, 2015
The GBMC HealthCare System Greater Baltimore Health Alliance (GBHA)(2011) ACO in the Medicare Shared Savings Program Private practicing physicians Greater Baltimore Medical Associates (GBMA) (200+) GBMC Medical Center (300 beds) Gilchrist Hospice Care (ADC 600) Circle of Life Award Winner (2012) 3 Inpatient Units Towson Howard County Baltimore City (Joseph Richey House) December 2014
GBMCs Two Foci of Care Management Greater Baltimore Medical Center Primary Care Patients of Greater Baltimore Health Alliance Patients of Other Primary Care Physicians or Those Who Have no Primary Care Physician 1. Hospital Based 2. Primary Care Based
The Patient Centered Medical Home Accountable Coordinated Available Health Information Technology myGBMC
The PCMH Care Team Physician Lead and Practice Manager Primary Care Providers Medical Assistants Care Manager Care Coordinator
Population Health Activities Monthly scorecard released to providers and practices Includes rankings by practice & provider Includes comparisons to GBMC, 60th percentile, & 90th percentile Monthly outreach emails to patients to encourage prevention & wellness (i.e., reminders about colon cancer screening) Identification and management of high hospital utilizers CRISP
Post Hospital Follow-up Visits 2014/2015 Care Team, % of Patients with a Visit to PCP within 14 days of hospital discharge 80% 68% 66% 64% 70% 60% 59% 59% 55% 60% 53% 49% 50% 40% 40% 30% 20% 10% 0% Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr
Care Teams Impact on Quality Metrics Consistent improvement has been measured on a monthly basis across all quality measures 8 measures have met the maximum threshold Decrease in healthcare utilization and expenditures as compared to the ACO cohort
LDL Control for Patients with Ischemic Vascular Disease Colon Cancer Screening 55% 55% 57% 55% 50% 50% 55.16% 54.98% 53% 48.64% 48.64% 53.79% 45% 45% 46.33% 46.33% 45.80% 45.80% 51% 51.66% 51.55% 40% 40% 42.55% 42.55% 42.53% 42.53% 50.77% 40.84% 40.84% 49% 49.85% 38.38% 38.38% 35% 35% 47% 30% 30% 45% Oct Oct Nov Nov Dec Dec Jan Jan Feb Feb Mar Mar Apr Apr Oct Nov Dec Jan Feb Mar Apr Breast Cancer Screening BMI Screening with Follow Up 69% 60% 68.18% 67% 55% 66.66% 65% 66.33% 50% 52.52% 63% 64.38% 50.57% 62.95% 61% 48.18% 62.26% 45% 61.64% 59% 43.95% 43.30% 42.88% 40% 42.58% 57% 55% 35% Oct Nov Dec Jan Feb Mar Apr Oct Nov Dec Jan Feb Mar Apr
MSSP Expenditures/Utilization - Trends Hospital Discharges GBHA 21.4% Decrease ( 83) ACO Cohort 13.2% Decrease ( 45) 10
MSSP Expenditures/Utilization - Trends ED Visits GBHA 12.1% Decrease ( 80) ACO Cohort 0.0 Increase ( 0) 11
MSSP Expenditures/Utilization - Trends Total Expenditures GBHA 6.8% Decrease ( $868) ACO Cohort 0.3% Increase ( $35)
Next Steps: Behavioral Health Integration People with mental health disorders (~25% of adult population) People with medical conditions (~60% of adult population) Population Surrounding GBMC ~65% of adults with mental health disorders have medical conditions ~30% of adults with medical conditions have mental health disorders
We are building a system of care for a better future for healthcare in our region Do not doubt that a small group of thoughtful people could change the world. Indeed, it's the only thing that ever has. -Margaret Mead
