Richard Honsinger MD, FAAAI, MACP
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1 Richard Honsinger MD, FAAAI, MACP Co-Chair Task Force on Care Coordination (PCMH-N), Council of Subspecialty Societies, ACP President, Joint Council of Allergy, Asthma and Immunology I have no conflict of interest to declare
2 Pro-Con NHLBI Guidelines Adherence DOES Lead to Improvements in Asthma Outcomes in Patient Centered Medical Homes.
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6 Patient Centered Medical Home What is it? Is it here to stay? Will it help asthma patients? Can the allergy/immunology specialist be a part of it?
7 History of PCMH American Academy of Pediatrics (1967) AAFP (2004) ACP (2005) Patient Centered Primary Care Collaborative(2006) IBM and 500 members of industry Joint Principles of PCMH AAP,AAFP,ACP,AOA (2007) NCQA: PCMH recognition program (2011)
8 National Committee for Quality Assurance NCQA (1990) Healthcare Effectiveness Data and Information Set (HEDIS) Accreditation Programs Accountable Care Organization (ACO) Wellness & Health Promotion (WHP) Health Plan Accreditation Behavioral Health Organization Recognition Programs Patient Centered Medical Home (PCMH) 2011
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11 Attributes of PCMH Comprehensive care Patient-centered Coordinated care Accessible services Quality and safety
12 PCMH Possible but difficult without EMR 3 levels of recognition Integrated with Meaningful Use
13 Meaningful Use _PCMH Patient portals Visit summary for each patient Registry and Search function Care Coordination with PCP E prescribing Mobile technology
14 6000 Medical Homes 30,000 Clinicians
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22 Basic Referral Form for All Referrals 1. Demographics ID, Insurance, contact info, specialist to contact patient? 2. Referral Information Question Urgency What type of Referral? Advice Non Face-to-Face Consult only Procedure Co-management with Shared Care (Call PCP first) Co-management with Principal Care (Call Specialist) Transfer of Care 3. Core Data Set 4. Care Coordination Receipt of the referral. Date of scheduled appointment Decision to defer appointment and reason why. Patient cancellation or no-show for the appointment. 5. Specific Specialty Template
23 Immunodeficiency Referral Template Preamble: Prepared by task force of AAAAI and ACAAI with approval by both organizations. Essential Patient Information: Description of infections, failure to thrive, family history of immune deficiency Additional Patient Information if available: Immunoglobulin (Ig GAME); CBC, Any lymphocyte analysis Alarm Symptoms: serious infections --sepsis, CNS infections Do Not: Do not give immunizations before consultation. The evaluation of the immune response is critical to the diagnosis. Do not administer live vaccines. Do not administer parenteral immunoglobulin without proving the lack of response to antigenic stimuli. (choosing wisely statement) Rule out: multiple myeloma in the adult References: Practice Parameter for the Diagnosis and Management of Primary Immunodeficiency. Ann Allergy 2005; 94:S1-S
24 Asthma Template Preamble: Prepared by task force of AAAAI and ACAAI with approval by both organizations. Essential Patient Information: Description of symptoms including severity, control, and limitations; treatments tried including current and past medications; diagnostic tests performed; past medical and surgical history including other atopic disorders; occupational or environmental risks; and family history of allergic diseases. Additional Patient Information if available: Spirometry or PFT results; radiographic study results (CXR, CT of sinus or chest, GI studies, etc.); relevant bloodwork (total & specific IgE, cbc, vitamin D3, alpha-1 anti-trypsin, etc.); previous allergy evaluation (skin tests, specific IgE tests); and notes from other care providers and specialists Alarm Symptoms: serious infections --sepsis, CNS infections, quickly worsening symptoms Do Not: Don t diagnose or manage asthma without spirometry [ Rule out: References: Attaining Optimal Asthma Control: A Practice Parameter. J Allergy Clin Immunol 2005;116:S3-11
25 Consumer Reports Foundation
26 Outcomes Measures ER visits Hospitalization Function PFT Activities School absenteeism Validated Tools (Questionnaires)
27 University of Illinois- Chicago PCMH 48 asthma patients Used Asthma Action Plan and monthly telephone management of patients in PCMH 7 of 9 uncontrolled became controlled 69% control improved to 83% Fam Med 2012 May;44(5):348-50
28 Patient Centered Medical Home What is it? Is it here to stay? YES Not Just For Primary Care Will it help asthma patients? YES Can the allergy/immunology specialist be a part of it? YES Medical Homes Do Lead to Improvement in Outcomes by Utilization of NHLBI Guidelines
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