Experience from the Front Line*: Patient-Centered Medical Home

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1 Experience from the Front Line*: Patient-Centered Medical Home Mark W. Friedberg, MD, MPP Natural Scientist RAND Presentation to the Roundtable on Value and Science-Driven Health Care Institute of Medicine March 12, 2014 *as an evaluator

2 Are patient-centered medical homes patient-centered? Theory: Of course! The Joint Principles say - The PCMH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient s family - Patients actively participate in decision-making and feedback is sought to ensure patients expectations are being met Implementation: An empirical question subject to measurement and evaluation Joint principles of the patient-centered medical home [March 2007]. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association 2

3 How can we measure patients and families involvement in a primary care practice? Structure Characteristics of the practice example: Having patient advisory board Process Care services for individual patients example: Patient being asked for his or her input in a clinical decision Outcomes Degree to which a patient actually experiences patient-centered care definition: Care consistent with medical science and with a patient s values, beliefs, and preferences Adapted from the classic Donabedian framework Donabedian A. Milbank Q 1966;44(3):

4 How can we measure patients and families involvement in a primary care practice? Structure Characteristics of the practice example: Having patient advisory board Interventions to improve Care services performance for individual patients in primary care Process act directly on example: the structure Patient being of asked primary for his or care her input in a clinical decision practices It is not possible to act directly on processes or outcomes Outcomes Degree to which a patient actually experiences patient-centered care definition: Care consistent with medical science and with a patient s values, beliefs, and preferences This is a key difference between a vision and an intervention Adapted from the classic Donabedian framework 4

5 Structural measures are valid only if they lead to better outcomes Structure Process Outcomes Characteristics of the practice example: Having patient advisory board Care services for individual patients example: Patient being asked for his or her input in a clinical decision Degree to which a patient actually experiences patient-centered care definition: Care consistent with medical science and with a patient s values, beliefs, and preferences?? 5

6 Have medical home interventions been associated with changes in patientcentered structures, processes, and outcomes? 6

7 PCMH and patient-centered structures NCQA recognition criteria (starting in 2008) encourage collection of patient experience data patient advocacy group or advisory board that meets regularly Some pilots also have incorporated patient input in their design Particularly successful example: Group Health Cooperative Improvements in patient experience and other goals Reid RJ, et al. Patient-centered medical home demonstration: a prospective, quasiexperimental, before and after evaluation. AJMC 2009;15(9):e

8 Effects on patient experience Where does patient experience fit? Some items are processes ( Did your doctor do X? ) Some items are service quality a type of outcome Two recent, rigorous evidence reviews reached similar conclusions (moderate strength of evidence): Small to moderate improvements in Overall patient satisfaction Patient-reported level of care coordination Peikes D, Zutshi A, Genevro JL, Parchman ML, Meyers DS. Early evaluations of the medical home: building on a promising start. Am J Manag Care. 2012;18(2): Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical home: a systematic review. Ann Intern Med. 2013;158(3):

9 More recent evidence on patient experience Two single-practice studies showed improvements in patient experience relative to comparison practices One was resident safety net clinic (Hochman et al) Better access but didn t get structural recognition One used Lean redesign (Heyworth et al) Better communication with care provider In 26 New Orleans safety net clinics, higher scores on a PCMH structural scale were associated with Better patient ratings of care coordination Worse patient ratings of access and confidence in quality and safety Hochman et al. Patient-centered medical home intervention at an internal medicine resident safety-net clinic. JAMA Intern Med 2013;173(18): Heyworth et al. Patient-centered medical home transformation with payment reform: patient experience outcomes. Am J Managed Care 2014;20(1): Schmidt et al. Transforming primary care in the New Orleans safety-net: the patient experience. Med Care 2013;51(2):

10 What about truly achieving patientcentered care, as an outcome? Structure Characteristics of the practice example: Having patient advisory board Process Care services for individual patients example: Patient being asked for his or her input in a clinical decision Outcomes Degree to which a patient actually experiences patient-centered care Care consistent with medical science and with a patient s values, beliefs, and preferences 10

11 Shared decision making in primary care Achieving truly patient-centered care means examining how clinical decisions are made Distinct from health outcomes Key sign of achievement: Patients do not all get the same care unless their preferences are identical (unlikely!) example: colonoscopy vs. occult blood testing Requires shared decision making A method to incorporate patient values and preferences A goal in some current pilots (example: CMS Comprehensive Primary Care initiative) Lin et al. Consequences of not respecting patient preferences for cancer screening: opportunity lost. Arch Intern Med 2012;172(5):

12 Key Steps of Shared Decision Making Based on Decision Aids Decision opportunity identification Decision aid use Post-DA conversation Health care delivery Opportunity recognized DA matched to opportunity DA distributed Patient uses DA Clarify medical information Elicit values and preferences Make shared decision Care consistent with final shared decision Friedberg et al. A demonstration of shared decision making in primary care highlights barriers to adoption and potential remedies. Health Affairs 2013;32(2):

13 Implementing shared decision making is complex and challenging in primary care Overworked physicians do not recognize decision opportunities and distribute decision aids reliably Providers lack training in shared decision making Inadequate clinical information systems - Not able to track the full sequence of steps involved in shared decision making - Not able to integrate with decision aids - Not able to ensure that subsequent care is actually consistent with shared decisions that have been made Clinics need new operating systems - Not just an app for shared decision making Friedberg et al. A demonstration of shared decision making in primary care highlights barriers to adoption and potential remedies. Health Affairs 2013;32(2):

14 Vulnerability in Later Steps of Shared Decision Making Decision opportunity identification Decision aid use Post-DA conversation Health care delivery Opportunity recognized DA matched to opportunity DA distributed Patient uses DA Clarify medical information Elicit values and preferences Make shared decision Care consistent with final shared decision Lack of longitudinal tracking can undermine early steps

15 How patient-centered are patient-centered medical homes? Depends on the specifics of implementation - Some pilot encourage patient-centered structural characteristics - Some pilots have produced evidence of patient-centered processes and good ratings of service quality No data yet on successfulness of shared decision making in medical home implementations - Quadruple axel of primary care: ability to do this well implies that many other capabilities are present and functioning - Given the degree of difficulty, expect some disappointments as practices figure out how to do this - Watch the measures in this space: distributing decision aids is not sufficient to guarantee that shared decision making has occurred 15

16 Thank you Mark Friedberg, MD, MPP 16