Patient Centered Medical Home Judith Schaefer, MPH MacColl Institute Missouri Foundation for Health September 27, 2010
What is the Medical Home?
History of Medical Home Pediatrics -Started as a movement to have the medical record stored in the pediatrician s office. Developed as a way to provide quality care for children with special healthcare needs. In 2002, grew into a concept for medical care.
Determinants of Health and Their Contribution to Premature Death 15% 30% 5% 10% Social Environmental Medical Behavioral Genetic 40% Schroeder, NEJM 357; 12
Delivery System Mismatch with Determinants of Premature Death Mental Health Specialists Specialists Financing Primary Care Hospital Services Hospital Services Community Patient Family Public Health Social Services This is how it looks now
Patient Driven Care Patients are the most important factor in their own outcomes (and need to do the heavy-lifting) Patients are the experts in themselves Health 2.0 is a Reformation What is role of Care Team? What is role for community? Services designed from patient point-ofview to meet patient needs and preferences
The Medical Home: It Depends on Your Point-of-View Hospital Services Family Clinician Practice Specialists Community Friends and Family Patient Internet Social Media Place of Worship Workplace Neighborhood Gym/ Recreation The empowered patient view a better match?
Conceptual model/ A philosophy process Specific delivery system definition Medical Home Designation through formal A way recognition of seeing
Joint Principles of a Medical Home Enhanced access Quality & Safety Integrated & coordinated care Continuous relationship Whole person orientation Payment Reform American Academy of Family Physicians. Joint principles of the Patient-Centered Medical Home. Del Med J. Jan 2008;80(1):21-22.
Joint Statement Definition The Patient-Centered Medical Home (PC- MH) is an approach to providing comprehensive primary care for children, youth and adults. The PC-MH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient s family. http://www.medicalhomeinfo.org/joint%20statement.pdf
Medical Home: Common Themes Reinvigorating Core Attributes of Primary Care (access, longitudinal relationships, comprehensiveness, coordination) Coordination of Care Across Settings (access to education/support programs and specialty care,) System supports for Chronic Illness Care (decision support, practice redesign, self mgmt, community links) Advanced information technologies (EMRs, registries, reminders, patient portals) Supportive payment methods
Medical Neighborhood Behavioral Health Integration Patients as Partners Population Health & Clinical Care Mgmt Care Coordination & Care Transitions
Imperative of Integration 1 of 15 programs showed significant reduction in hospitalizations. Only two programs appear to have made clear improvements in the quality of preventive care. The Evaluation of Medicare Coordinated Care Demonstration: Findings for the First Two Years. (2007) Brown, Peikes, Chen, Ng, Schore, Soh.
Aligned with the Chronic Care Model Comprehensive Medical Home Model Advanced Medical Services Model We are still figuring this out. This is where much of the work has been focused.
PATIENT-CENTERED MEDICAL HOME EMPANELMENT ENGAGED LEADERSHIP Patient And Family ENHANCED ACCESS CONTINUOUS, TEAM-BASED HEALING RELATIONSHIP QUALITY IMPROVEMENT STRATEGY COMMUNITY MEDICAL AND SUPPORT SERVICES CARE COORDINATION Informed, Activated Patient ORGANIZED, EVIDENCE-BASED CARE Productive and PATIENT-CENTERED INTERACTIONS Care that patients want and need When they want and need it. Prepared, Proactive Practice Team Reduced healthcare costs.
PCMH Change Concept Engaged leadership QI Strategy Empanelment Patient-centered Interactions Organized, Evidence-based Care Continuous and Team-Based Healing Relationships CCM Element Health Care Organization Health Care Organization--QI strategy Clinical Information Systems IT functionality Delivery System Redesign population management and proactive care Self-management support Delivery system Design health literacy Delivery System Design planned care Decision Support integrated guidelines, reminders Delivery System Design team care Enhanced Access Care Coordination Delivery System Design care management Community resources
Group Health Research Institute Annual Report. (2008)
Medical Home Conveners Purchaser Coalition Private Payers Public Payers Innovative State Executives Foundations Multistakeholder Collaboratives Public Health Departments Patient Centered Primary Care Collaborative www.pcpcc.net Group Health, Geisinger, Care Oregon Medicare Demo, many state Medicaid agencies e.g. Community Care of North Carolina Pennsylvania, Massachusetts Commonwealth Fund: Safety Net Medical Home Initiative, Robert Wood Johnson Foundation: IPIP Maine, Colorado, Greater Cincinnati Aligning Forces for Quality Washington
Quality Improvement Engaged Consumers Publicly-Reported Quality Measures Improved Health and Healthcare in South Central PA (York/Adams Counties) Courtesy of Christine Amy, camy@wellspan.org AF4Q Key Driver Diagram 9.3.08
Better Health Together We Can Campaign www.aligning4healthpa.org website Consumer Research Panel Health Literacy Task Force Physician Advisory Council Nurses Council GOHCR Regional Collaborative PCMH Hospital Nurse Leadership Collaborative TCAB Engaged Consumers Quality Improvement Improved Health and Healthcare in South Central PA (York/Adams Counties) Hospital Race, Ethnicity and Language Collaborative Data Aggregation Model South Central Preferred Quality Bonus Program Physician Participation Data Analysis Strategy Data Audit Process Consumer Friendly Reporting on www.aligning4healthpa.org Ongoing Dialogue with Physicians About Results Publicly-Reported Quality Measures Courtesy of Christine Amy, camy@wellspan.org AF4Q Key Driver Diagram 9.3.08
Humboldt County Aligning Forces for Quality Chronic Care Model elements: IPA-led community wide improvement effort Health IT: Chronic Disease registry Decision Support: E-referrals, disease specific guidelines Self-Management Support: Health Education Alliance Delivery System Design: Care Support Primary Care Renewal: IPA-led build your own medical home collaborative Care Support of high-risk patients harm-reduction strategy Our Pathways to Health: peer-led SMS Kate Lorig Model Care Transitions: RN-led hospital program for ED and postadmit patients Comparative Performance Reporting: Triple Aim Population Health: HMO and PPO Measures (HEDIS) Patient Experience: CAHPS (PAS in CA) Efficiency Measures: Total Cost of Care, ED visits, bed days, generics, imaging for LBP, 30-day readmits, evidence-based cervical cancer screening
Primary Care Renewal The only way to know is to try Build Your Own Medical Home Defining key principles allows each to create the medical home ideas and practices that work for them and might be useful to others
Group Health Medical Home Medical Home Principles Standard Work Elements FOUNDATION
Medical Home Principles FOUNDATION The relationship between the personal care physician and the patient is the core of all that we do; we organize the delivery of care around this relationship. The personal care physician will lead the clinical team in coordinating & integrating of services to meet patients needs. Continuous healing relationships between the patient, the personal physician and the care team will be proactive and encompass all the aspects of health and illness. Patients will be actively engaged to participate in all aspects of their care. Access will be centered on patients needs, be available by various modes 24/7 and maximize the use of technology. Our clinical and business systems are aligned to achieve the most efficient, satisfying and effective patient experiences.
Medical Home - Standard Work FOUNDATION Customer Focused Management Training (CFMT) Call Management Virtual Medicine Chronic Disease Management Pre-Visit Outreach Workcell Variable Visit Lengths for Patients Smaller Panels for Family Medicine, General Internists
What Happened Catharine Gottlieb, CEO Southcentral Foundation, Alaska 15 years ago: Apartheid-like health care Bureau of Indian Affairs created local option Catharine and leaders ruthlessly asked: Why can t Native Americans have World Class Care?
Seven Requirements to Shift the Model of Care 6. Payment Incentives to Enable and Sustain The new Model Appreciation of A System 1. Consumer Centric Processes And Outcomes Psychology 2. Primacy of Relationship And behavior Change 5. Integration with The Larger, Whole System Deming s Profound Theory of Knowledge Theory of Knowledge 4. Learning Center To Deepen Expertise And Execution Understanding Variation 3. Core Five Primary Care Elements Source: Observations of Southcentral Foundation
Building a Robust Medical Home Subset of SCF Whole System Integration Project Collaborative 1. Member/Patient Values 2. Open Access 3. Empanelment Data Review 4. Team Based Care: MD Nurse CM CMA CMA 5. Behavioral Specialist Outcome And Result Measures From Southcentral Foundation, Anchorage, AK
Paying for the Medical Home Enhanced payment for recognition Pay for performance arrangements Driving savings with efficiency Outrunning the bear with innovation IT, Beacon Grants
AFFORDABLE EXCELLENCE Enrollment Costs Outcomes // Patient & Staff Satisfaction Outreach Standard Work Pre-Visit MORE TIME Disease Management MHM Call Management Virtual Medicine Panel Leveling MORE TIME Access Tools
No. of Daily Contacts No. of Daily Contacts Average daily Touches before panel management Source: 80 70 60 50 40 30 20 10 0 More Touches -- Fewer Visits 1 Office visits Transforming Office Based Care FFS Doctor s View Of Change 80 70 20 10 CEC Presentation 5/2/2005 Gerard F Livaudais MD, MPH Kaiser Permanente Hawaii Region 0 Average Daily Touches with panel management Unpaid 60 Care in 50 Today s 40 FFS 30 Model 1 US mail contacts RN and HCT contacts Email contacts Phone contacts Annual health goals "Fast Track"'s Group visits Office visits
Revenue Business Problem Medicare and Medicaid Medical CPI CPI Public Rate Range Time
Revenue Time Business Problem Medicare and Medicaid Medical CPI CPI Public Rate Range
Co Designed Payment Pilot Quarterly payments to PCR medical home clinics based on member assigned, beginning Jan 2009 Variable payment based on cumulative scoring: Tier 1: Pay improvement capacity: Participate in PCR Collaborative, workgroups, learning sessions Report all required data; perform satisfaction surveys Risk adjustment for higher acuity population Tier 2: Pay for improvement Pay for target % improvement in key measures (access, HEDIS) Pay for full participation in care management learning collaborative Tier 3: Pay for outcomes Pay for achieving Plan HEDIS Benchmarks Pay for decrease in ambulatory sensitive Hospital admits, ED visits Prediction: Pay 100% full Tier 1; 60% full Tier 2; 20 % full Tier 3 If $3-2-1 and risk adjustment, average pmpm = $4.50
Lesson from the Swedes Create an Engine for Improved Efficiencies to Fuel Continuous Transformation over time Incremental Increase Current 100% Budget
Gnarly Issues Measurement UDS and HEDIS measures not aligned with PCMH concepts of care Even with EMR s, difficult to extract data for quality improvement Measuring patient experience of care is nascent Information technology EMR s make reporting much easier, but Many sources of funding, confusing, not aligned in a region Meaningful use reporting on specific measures not aligned
Challenges Remaining What should live in primary care? Linking patients to programs Incentives & culture change Create supportive systems
Questions Judith Schaefer, MPH MacColl Institute for Healthcare Innovation Group Health Research Institute Schaefer.jk@ghc.org
Tools and Resources Session Judith Schaefer
PCMH and QI Tools and Resources Improving Chronic Illness Care Chronic Care Model Organizing conceptual framework ACIC Measure, but especially guidance for CCM progress PACIC Patient experience of care loosely based on CCM PCMH-A Measure, but guide for PCMH progress
Patient Centered Primary Care Collaborative Center for Multi-Stakeholder Demonstrations (CMD) Center for Consumer Engagement (CCE), Employers and Health Plans Providers and Clinicians Federal and State Governments
Practice Resources American College of Physicians ACP Medical Home Builder http://www.acponline.org/running_practice/pc mh/help.htm American Academy of Pediatrics http://www.pediatricmedhome.org/ TransforMED http://www.transformed.com/transformed_is_ How.cfm
Commonwealth Fund Safety Net Medical Home Initiative Webinars e.g. Intro to PCMH video Wagner Issue Briefs Implementation Guides for Change Concepts Medical Home Digest Many tools http://www.qhmedicalhome.org/safetynet/publications.cfm