OU School of Community Medicine—Patient-Centered Medical Home Project

Region Within State: 
Tulsa—North Eastern Oklahoma
Project Category: 
Insurer-Based
PROJECT STATUS
Target Start Date: 
Tuesday, September 30, 2008
Pilot/Demo Length: 
3+ years

The project is designed to transform the teaching clinics of the University of Oklahoma School of Community Medicine into the PCMH. This pilot was initiated in response to the Oklahoma Health Care Authority’s (Medicaid) change from pure capitation to fee-for-service plus a capitated fee for care management. OU intends to shape its teaching clinics on the medical home model. We wish to demonstrate that patients will have better access to primary and specialty care, increased access to medical advice, more efficient and effective treatment for chronic care, improved support and education for meaningful lifestyle changes and proactive, holistic health care instead of reactive responses to symptoms.

The Tulsa and Northeast Oklahoma community will benefit by having fewer ER admissions for acute primary care, fewer relapses of chronic conditions, and improved mental and physical health-related behaviors that will result in better overall health trends. OU Physicians practices will provide proactive instead of reactive care, form integrated health care teams, improve communications between care teams, prevent conflicting treatment plans or missed services, and permit all professionals to practice at the top of their license.

CONVENING ENTITY/PROJECT CONTACTS
Convening Organization Name: 
Oklahoma Health Care Authority (Medicaid) payor
Primary Contact: 
F. Daniel Duffy, MD, MACP
E-mail: 
[email protected]
Phone: 
918/660-3095
Additional Contact
Name: 
Kim Johnson
Participating Stakeholders: 

University of Oklahoma School of Community Medicine; Oklahoma Health Care Authority.

EXPECTED OR ACTUAL DEMOGRAPHICS OF PARTICIPATING PRACTICES
Number of Practices: 
4
Types of Practices: 
Internal Medicine, Family Medicine, Pediatrics Health Plan
Health Plan Lines of Business Included: 
Medicaid Managed Care
Overall Number of Covered Lives: 
30000
Technology Characteristics at Start of Pilot: 

Estimated % of practices with practice management systems: >95%
Estimated % of practices with electronic medical record: >95%
Estimated % of practices with registry software: <5%
Other: Consultation and referral software

PRACTICE TRANSFORMATION SUPPORT (INCLUDING TECHNOLOGY)
Focal areas of transformation: 

Care Coordination
Increased Access Information Technology (e.g., registries, patient portals)
Team Approach to Care

Services participating practices have added as a result of their participation: 

More effective use of EMR for decision support, screening for mental and behavioral health problems, electronic submission of consultations and referral requests, addition of social workers to provide care coordination.

Payment Model: 

Fee for service payments are provided for services delivered by participating practices. An additional payment for care management will be paid on a per member per month basis according to the medical home tier designation. An additional payment for the Health Access Network of practices will be paid when the waiver has been obtained.

PROJECT EVALUATION
Types of data to be collected : 

Clinical Quality Cost/Efficiency Patient Experience/Satisfaction Provider Experience/Satisfaction
The routine collection of clinical measures for well child examinations, preventive services, and chronic illness processes (diabetes, asthma) are planned to be collected over the course of the pilot. Every six months patient and staff satisfaction measures are being collected. Monthly reports of practice cost and efficiency are reported.

Results to Share: 

Yes. All of the practices have assigned patients to physician directed care teams. Health risk appraisals, mental and behavioral health screening has begun. Proactive contact of patients for screening and chronic illness care has started. A PCMH patient-provider contract has been initiated. The EMR forms have been re-designed to incorporate the principles of organized data collection for the medical home. Outbound calls have been initiated to engage patients in their own care.

Relevant links: 

http://tulsa.ou.edu/docs/index.htm http: /tulsa.ou.edu/ socm/action.htm#1