Patient-Centered Medical Home Kevin A. Dorrance, MD, FACP Associate Professor of Medicine USUHS Chief Medical Officer BUMED September 2011 7-1
Disclosure Presenter has no financial interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with the MedXellence Program. PESG, and MedXellence Staff, and accrediting organization do not support or endorse any product or service mentioned in this activity. PESG and MedXellence Program staff have no financial interest to disclose. September 2011 7-2
Learning Objectives 1. Understand the structure and function of the PCMH model 2. Show how the principles of PCMH align with the goals of the MHS 3. Understand the collaborative care model as it relates to primary care September 2011 7-3
Overview Patient-Center Care Health Crisis and Health Care PCMH Model HRO Team Based Care Access: Traditional and Enhanced Continuity Enrollment September 2011 7-4
Patient-Centered Care It s Obvious When You See It! 7-5
Patient-Centered Care And When You Don t! 7-6
Leading vs. Actual Causes of Death 7-7
Behaviors and Health Over 1/2 of Americans do not meet the recommended aerobic activity level 1 1/3 of US population is obese 2 1 in 5 Americans smoke cigarettes 3 1 in 4 ages 18 or older engaged in binge drinking in the past month; 7.1% engaged in heavy drinking in the past month 4 1. Centers for Disease Control and Prevention. Exercise or Physical Activity. NCHS FastStats Web site. http://www.cdc.gov/nchs/fastats/exercise.htm. Accessed December 20, 2013. 2. Ogden, Cynthia L., Margaret D. Carroll, Brian K. Kit, and Katherine M. Flegal. "Prevalence of childhood and adult obesity in the United States, 2011-2012." JAMA 311, no. 8 (2014): 806-814. 3. US Department of Health and Human Services. The Health Consequences of Smoking 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Dept of Health and Human Services, Centers for Disease Control and Prevention; 2014. http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. Accessed February 7, 2014. 4. SAMHSA. 2012 National Survey on Drug Use and Health (NSDUH). Table 2.46B Alcohol Use, Binge Alcohol Use, and Heavy Alcohol Use in the Past Month among Persons Aged 18 or Older, by Demographic Characteristics: Percentages, 2011 and 2012. Available at: http://www.samhsa.gov/data/sites/default/files/nsduh-dettabs2012/nsduh-dettabs2012/html/nsduh-dettabssect2petabs43to84-2012.htm#tab2.46b 7-8
Putting it in Perspective Top 10 US Public Health Achievements Vaccination Motor vehicle safety Safer workplaces Control of infectious diseases Decline in deaths from coronary heart disease and strokes Safer and healthier foods Healthier mothers and babies Family planning Fluoridated drinking water Recognition of tobacco as a health hazard Health care has had little to do with increased life expectancy over time. 7-9
Quality of Care Study evaluated performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care using medical records from a two-year period of a random sample of adults living in 12 metropolitan areas in the United States. Participants received 54.9% of recommended care: Proportion of recommended preventive care provided (54.9%). Proportion of recommended acute care provided (53.5 percent). Proportion of recommended care provided for chronic conditions (56.1%). Among different medical functions, adherence to established care processes ranged from 52.2% for screening to 58.5% for follow-up care. Quality varied substantially according to the particular medical condition, ranging from 78.7% of recommended care for senile cataract to 10.5% of recommended care for alcohol dependence. McGlynn, Elizabeth A., Steven M. Asch, John Adams, Joan Keesey, Jennifer Hicks, Alison DeCristofaro, and Eve A. Kerr. "The quality of health care delivered to adults in the United States." New England journal of medicine 348, no. 26 (2003): 2635-2645. 7-10
Reality in Primary Care To fully satisfy the USPSTF recommendations, 1773 hours of a physician s annual time, or 7.4 hours per working day, is needed for the provision of preventive services 1 Competing priorities and system limitations Acute Care Chronic Care Access and Enrollment HIT..others If lucky, PCMs can address other secondary physical complaints If really lucky, PCMs can meaningfully address health behaviors If really, really lucky, PCMs can address subclinical corroborating/comorbid psychological problems 1. Yarnall, Kimberly SH, Kathryn I. Pollak, Truls Østbye, Katrina M. Krause, and J. Lloyd Michener. "Primary care: is there enough time for prevention?" American journal of public health 93, no. 4 (2003): 635-641. 7-11 PCBH SME
Here We Are The Consequences Episodic model of disease care A growing prevalence of preventable chronic diseases 75% of direct health care costs Our continuing failure to proactively monitor and improve the overall health of our population has facilitated the growth of our current disease model of care. 7-12
Here We Are Test and prescribe vs. prevention and healing. 7-13
Here We Are Current Healthcare Model Episodic Primary Care Primary Care Is Devalued Hospital Emergency Room Uncoordinated Network Care Specialists Ancillary Support Disease Model Community Nursing Homes Assisted Living 7-14
HRO Principles Preoccupation with failure: Identification of risk, viewing near-misses as evidence of systems that should be improved rather than as proof that the system has effective safeguards. Reluctance to simplify: Simplistic explanations for why things work or fail are risky. Avoiding overly simple explanations of failure (unqualified staff, inadequate training, communication failure, etc.) is essential. Deference to expertise: Willingness to listen to the insights of staff who know processes and the risks patients face. Sensitivity to operations: Constant awareness by leaders and staff of the state of systems and processes. Resilience: Leaders and staff need to be trained and prepared to know how to respond to system failures. 7-15
Organizational Habits Destructive organizational habits can be found within hundreds of industries and at thousands of firms. And almost always, they are the products of thoughtlessness, of leaders who avoid thinking about the culture and so let it develop without guidance. There are no organizations without institutional habits. There are only places where they are deliberately designed, and places where they are created without forethought. * *Charles Duhigg, The Power of Habit: Why We Do What We Do in Life and Business We need deliberate design to drive organizational culture 7-16 16
Joint Principles of PCMH Personal physician Physician directed medical practice Whole person orientation Care is coordinated and/or integrated Enhanced access Quality and safety Payment reform 17 7-17
Traditional Workflow Design Preventive Medicine Chronic Disease Monitoring Medication Refills Acute Care Test Results PROVIDER Healthcare Support Team Case Manager Behavioral Health Medical Assistants Nursing 7-18
Medical Home Model Holistic Approach Partnership with Patients and Families Comprehensive Spectrum from wellness to end of life Coordinated Team Approach Across Specialties Patient-Centered Enhanced Access Consistent PCM Continuity 7-19
Parallel Workflow Design Medication Refills Chronic Disease Monitoring Test Results Acute Care Preventive Medicine Point of Care Testing Acute Mental Health Complaint Behavior Modification Chronic Disease Compliance Barriers Healthcare Support Team Case Manager PROVIDER Provider Medical Assistants Behavioral Health 7-20
Team Based Care Team Composition: Internal/Family Medicine, Advanced Practice RN, PA, RN, LPN, HM/Medic, Clerical Support Collaborative: All members engaged in preventive and chronic care Team members with expanded skills and training Integrated care model Behavioral health Clinical Pharmacist Dieticians PT SW/CM 7-21
Team Formation Policy Process Team Building Execution Roles & Responsibilities Check lists SOP s: Standard Work Monitoring and Feedback Change Management! Why we fail: Must involve people Systems approach Standards not Standardization Clearly defined outcomes Timely feedback Visual dashboards 7-22
Outcome Measures The Bottom Line Care delivered by primary care physicians in a patient-centered medical home is consistently associated with: Better outcomes Reduced mortality Fewer hospital admissions Lower utilization Improved patient satisfaction Lower Cost 7-23
Discussion Variable success..why? 7-24
Access Redefining Access What is access? Is access proportional to available appointments? How should we measure access? acute vs. routine 7-25
Enhanced Access In-person encounters Telephone Automated medication refills Relay Health NAL Telemedicine Open access preventive care 7-26
Improving Access to Care Reducing artificial demand Scrubbing schedules: Impact of call centers Removing barriers Chronic/preventive care Process based management: standard work Proactive appointing and asynchronous visits Open access Patients are seen right setting right time Template management 7-27
Continuity Trust Affability/Availability/Accessibility/Accountability Communication Time Acute care vs. Chronic care When does continuity matter? Transitions 7-28
Enrollment Increases as PCMH Matures Area Startup Today IM 600 860 FP 1000 1180 PA/NP 1000 1360 Acuity based enrollment: Understanding your population Recent study in FM suggests 1,600 Patients/FTE in fully optimized PCM 7-29
Lessons Learned Culture change: don t underestimate Training, team building Measuring for success Persistent and Predictive Productivity: Beyond RVU s How do we measure non-traditional care? Staffing model: what is optimal? Transformation: where to start? HRO Principles Wellness focus: population health has to be at the center of all elements of care 7-30
Discussion 7-31
Back Up 7-32
Outcome Measures Continuous Enrollment Impact (quarterly utilization and cost) Total Chronic Non-chronic Average use Cont enr impact Change Average use Cont enr impact Change Average use Cont enr impact Change IP adms 0.0351-0.0176-50.0% 0.0780-0.0421-53.9% 0.0097-0.0032-33.4% IP days 0.2455-0.1472-59.9% 0.5440-0.3399-62.5% 0.0636-0.0351-55.1% ER visits 0.1775-0.0388-21.9% 0.2828-0.0953-33.7% 0.0821-0.0037-4.5% Specialty care Primary care 2.4688-0.2319-9.4% 3.4033-0.4031-11.8% 1.1993-0.0519-4.3% 1.8293-0.0190-1.0% 2.4037-0.0868-3.6% 1.0023-0.0015-0.2% Pharm. $91.10 $4.83 5.3% 156.31 -$2.13-1.4% 22.40 $3.43 15.3% Ancillary $83.42 $3.52 4.2% 118.01 -$0.43-0.4% 43.82 $4.61 10.5% PMPQ $481.51 -$38.09-7.9% 791.67 -$123.3-15.6% 174.94 $2.46 1.4% 7-33
Outcome Measures WRB Medical Home Impact(quarterly utilization and cost) Total Chronic Non-chronic Average use PCMH impact Change Average use PCMH impact Change Average use PCMH impact Change IP adms 0.0215-0.0009-4.4% 0.0439 0.0074 IP days 0.1016 0.0193 19.0% 0.2098 0.0393 18.7% 0.0331 ER visits 0.1574-0.0107-6.8% 0.2204-0.0161-7.3% 0.0891 Specialty care Primary care 2.2454 0.0535 2.4% 3.1946-0.0989-3.1% 1.0203 0.1480 14.5% 1.5037 0.3199 21.3% 1.8500 0.5002 27.0% 0.9396 0.0011 0.1% Pharm. $112.16 -$14.45-12.9% $182.90 -$25.41-13.4% $27.49 -$2.35-8.5% Ancillary $104.23 -$16.57-15.9% $144.80 -$25.06-17.3% $53.95 -$6.76-12.5% PMPQ $507.49 -$46.67-9.2% $784.00 $-83.16-10.6% $187.44 -$13.29-7.1% 7-34
Outcome Measures WRB Medical Home Impact by Condition Diabetes Hypertension Hyperlipidemia COPD CAD Mental health IP adms -10.8% IP days 20.2% 19.0% 36.0% ER visits -13.5% Specialty care -3.6% -0.5% 3.4% Primary care 40.3% 32.0% 32.1% 46.3% 49.3% 24.8% Pharmacy -17.0% -16.1% -17.0% -10.3% NA* -1.4% Ancillary -16.2% -19.1% -15.2% -24.0% -24.1% -14.1% PMPQ -10.5% -11.1% -10.0% -10.1% -8.2% NNMC enrollees 1,595 7,098 7,207 960 659 2.426 7-35
Outcome Measures Cost Impacts Associated with Chronic Enrollees Estimated costs per enrollee Chronic Nonchronic PMPY without PCMH $3,136 $750 PMPY with PCMH $2,803 $697 Change -$333 -$53 Change -10.6% -7.1% Average PMPY change by percent chronic Total Change attributable to chronic 40% -$165 80.7% 50% -$193 86.2% 60% -$221 90.4% 7-36