Treating sinusitis? Managing obesity? Preventing heart disease? Preventing lung cancer? Managing individuals with multiple chronic diseases?

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3 Treating sinusitis? Managing obesity? Preventing heart disease? Preventing lung cancer? Managing individuals with multiple chronic diseases? Providing care for long-term cancer survivors? Managing depression? Treating substance abuse?

4 A. The US doesn t spend enough on health care. B. Doctors don t know these are problems that should be addressed. C. Competing demands make it impossible to do everything. D. Practices are designed for care of acute problems and single chronic diseases. E. The United States doesn t address the underlying determinants of health.

5 In late January 2015, Tom s father was diagnosed with Acute Myelogenous Leukemia. This was quite a shock as his father had been walking nearly eight miles a day through the end of 2014 and had otherwise been very healthy. As a result of his diagnosis, Tom s father was hospitalized for a couple of weeks and is now completing his second round of chemotherapy.

6 What struck Tom as he sat in his father s hospital room the first week after he was diagnosed was how little choice his dad was given in his treatment. He particularly noted the nurses and oncologists being clear that they would be meeting without his dad to determine the best course of treatment and they would let him know how they would proceed. A couple of years previously, before his role as Executive Director of NAPCRG, it may have been reassuring or comforting that the doctors were handling things on behalf of his dad. But now, he was actually quite shocked by their complete lack of consideration for what his dad might actually want in terms of his treatment.

7 After spending the better part of the past two years working alongside Jack Westfall, MD to create and manage the Patient and Clinician Engagement initiative that PCORI has generously funded - it was like a light went off in my brain and now I can t shut it off. My observations of my dad s care do not square with the values we are working to achieve in valuing and respecting the patient first and foremost. I suddenly had a very real and deep appreciation for our work and I m grateful for it.

8 Adult population at risk Adults reporting one or more illnesses or injuries per month Adults consulting a physician one or more times per month Adult patients admitted per month Adapted from Adult patients referred to another physician per month Adult patients referred to a university medical center per month

9 Helen slumps in the corner of the exam room. Dr. Jones, a family doctor, enters for his 10 minute visit. Dr. Jones looks at Helen and asks, How many seizures are you having? This is the 12th visit in 2 years with multiple providers for this 46 year old woman with chronic problems of abdominal complaints, seizures, hypertension, type 2 diabetes, and depression. How can Dr. Jones meet the patientcentered needs of Helen? 9

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11 Barbara Starfield s international comparisons of primary care and the lag by US IOM Chasm Report of 2001 finds huge quality gaps Future of Family Medicine Report of 2004 proposes major practice redesign NCQA, ACA, Meaningful Use and a whole host of disruptions!

12 Chronic Care Model Resources and Policies Community Health System Health Care Organization Community and Practice Resources Self- Management Support Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes 12

13 ACO & PCMH Corporate, Retail Employed Practices Small Independent Practices Small Independent Practices

14 2000 Keystone III Conference Family Medicine recognition that the health care system is in serious trouble, commissioned study in Future of Family Medicine Report New Model of practice and recommended proof of concept demonstration project in typical family practices 2006 AAFP creates TransforMED and begins NDP 36 family medicine practices randomized to two arms to implement NDP Model with independent evaluation

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16 2007 Joint Principles of a Patient Centered Medical Home AAFP, ACP, AAP and AOA release consensus statement 2007 NCQA announces Physician Practice Connections A program with criteria that medical practices should meet to be recognized as medical homes 2008 Primary Care Patient-Centered Collaborative Announces16 significant state-level or multi-payer medical home demonstration projects are underway.

17 Access and communication Patient tracking and registries Care management Patient self-management support Electronic prescribing Test tracking Referral tracking Performance reporting and improvement Advanced electronic communications

18 2010 ACA in March 2010 creates integrated delivery systems platforms with PCMH often a major part Accountable Care Organizations (ACOs) take off 2011 NCQA Updates Recognition Criteria New NCQA criteria are announced with the PCMH Survey tool. This was updated again in Struggles continue to define ACOs and the role of the PCMH and primary care within ACOs

19 Patient Centered Medical Home

20 Team of people embedded in a community seeking to improve health and healing in that community & consisting of: Fundamental tenets of primary care First contact access Comprehensiveness Integration / coordination Relationships involving sustained partnership New ways of organizing practice Development of practice internal capabilities Health care delivery system & payment changes

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23 Vermont Blueprint for Health created Community Health Teams to work with primary care providers to assess patients needs, coordinate support services, and provide multidisciplinary care. Web-based central health registry of patient data. State support for practice facilitators to work with primary care practices to obtain NCQA PCMH Recognition.

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26 Virginia Mason Bainbridge Island adopted Toyota Lean and taught this to all leaders and many staff. Using their existing personnel, they created teams of 2 physicians, one mid level, 1 RN, and 2 MA s, with all teams sharing a clinical pharmacist. Joint workspaces created for MA s/clinicians, with nurses located. Created Flow Stations by up-skilling traditional MA roles and creating partnerships of a clinicians and MA s who always worked together. MA called flow manager and manages the flow of patients and all the paperwork. Pharmacy and Care manager are available if needed to keep things flowing. All work is finished by end of the day.

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29 Lehigh Family Medical Associates combined elements of Virginia Mason and the Vermont Blueprint. Created Community Health Teams to work with primary care providers to assess patients needs, coordinate support services, and provide multidisciplinary care. Using their existing personnel, they created teams of physicians, mid-levels, RN s, and MA s who also work together.

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32 Southcentral Foundation is an Alaska Nativeowned, nonprofit health care organization run by a community board Primary care provider and teams include: One or two medical assistants Full-time nurse care coordinator Administrative assistant for case management support Members added or subtracted needs change: Pharmacists Nurse midwives Chiropractors Other specialists Reduced urgent care and ER utilization by 50%, hospital admissions by 53%, and specialist use by 65% while rising to the 75-90th percentile on most HEDIS outcome and quality measures.

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37 NCQA Recognition Accountable Care Organizations Meaningful Use Pay for performance on disease outcomes Employer mandates

38 46% Use of information technology 14% Care for 3 specific chronic diseases 13% Systems for coordinating care 9% Processes for accessibility 5% Performance reporting 4% Tools for organizing clinical data 2% Use of non-physician staff 2% Collection of data on patient experience 1% Preventive service delivery 1% Continuity of care 1% Patient communication preferences O'Malley AS, Peikes D, Ginsburg PB. Qualifying a Physician Practice as a Medical Home Policy Perspective: Insights into Health Policy Issues. No. 1 December, Available at:

39 Network of doctors and hospitals that share financial and medical responsibility for providing coordinated care. Since January 2013, nearly 200 new public and private ACOs have been formed: Medicare Shared Savings Program (MSSP) Accountable Care Organizations Medicaid Accountable Care Organizations Integrated Delivery Systems Multispecialty Group Practice (usually don t own the health plan, but contract with multiple plans) Independent Practice Associations Drastic shift away from private independent practices to affiliated and owned practices

40 Implement drug-drug and drug-allergy interaction checks Maintain up-to-date problem list of current and active diagnoses Generate and transmit permissible prescriptions electronically Maintain active medication list Record demographics and vital signs Implement clinical decision support rule for high clinical priority and track compliance Patients can view online, download, and transmit information Provide clinical summaries for patients for each office visit

41 Focus on technology for information management and control Diseases controlled care and not necessarily patient-centered care Focus on corporate mandates

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44 Crabtree BF, Nutting PA, Miller WL, McDaniel RR, Stange KC, Jaen CR, Stewart EE. Primary care practice transformation is hard work: Insights from a 15 year developmental program of research. Medical Care, 49(Dec Suppl): S28-35, 2011.

45 Observation DOPC Direct Observation of Primary Care ( ) NCI R01 P&CD Prevention & Competing Demands in Primary Care ( ) AHRQ R01 IMPACT Insights from Multimethod Practice Assessment of Change over Time ( ) NCI R01 Intervention STEP-UP Study To Enhance Prevention by Understanding Practice ( ) NCI R01 ULTRA Using Learning Teams for Reflective Adaptation ( ) NHLBI R01 SCOPE Supporting Colorectal Outcomes through Participatory Enhancements ( ) NCI R01

46 Follow-up Baseline Motivation of key stakeholders Motivation, Innovation & Independence Resources & Capability for change External contingencies & capability to change Co-evolution & response to interventions Evaluating & exercising choices for change Outside Motivators External influences on change option landscape Choices for Change Cohen D, et al. A practice change model for quality improvement in primary care practice. J Healthcare Management, 49(3):155-68,

47 Observation DOPC Direct Observation of Primary Care ( ) NCI R01 P&CD Prevention & Competing Demands in Primary Care ( ) AHRQ R01 IMPACT Insights from Multimethod Practice Assessment of Change over Time ( ) NDP NCI R01 National Demonstration Project ( ) Intervention STEP-UP Study To Enhance Prevention by Understanding Practice ( ) NCI R01 ULTRA Using Learning Teams for Reflective Adaptation ( ) NHLBI R01 SCOPE Supporting Colorectal Outcomes through Participatory Enhancements ( ) NCI R01

48 Practices are complex systems Change is HARD RELATIONSHIPS matter LEADERSHIP is key PERSONAL transformation is needed There is no such thing as Plug n Play The promise of the patient-centered medical home remains elusive AND, the healthcare world is rapidly changing and our thinking needs to extend beyond the individual practice.

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51 Does community ownership change the model? What is the impact of hierarchical corporate governance? What is the appropriate corporate scale? (local, regional, national) What kind of ACO can be family and patientcentered? (physician led, hospital led, community led) What is a Patient-Centered Health Care Neighborhood?

52 Current physicians (and others) must transform themselves. Future professionals need to learn the basics of leadership, teamwork, and organizational behavior. New professional roles need to be conceptualized and programs created to train for the future. Cultures of teamwork and collaboration need to be established within and across primary care and specialty practices, as well as throughout the neighborhood.

53 We need new comprehensive study designs Scammon D, et al. Connecting the Dots and Merging Meaning: Using Mixed Methods to Study Primary Care Deliver Transformation. Health Services Research, 2013; 48(6 Pt2):

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