PHCPI framework: Presentation Crosswalk to Service Delivery Elements

C1. Facility Organization and Management

C1.a Team-based care organization

C1.b Facility management capability and leadership

C1.c Information systems

C1.d Performance measurement and management

C3. Access

C3.a Financial

C3.b Geographic

C3.c Timeliness

C4. Availability of Effective PHC Services

C4.a Provider availability

C4.b Provider competence

C4.c Provider motivation

C4.d Patient-provider respect and trust

C4.e Safety

C5. High Quality Primary Health Care

C5.a First Contact C5.b Coordinated C5.c Comprehensive C5.d Continuous C5.e Person-Centered

C2. Population Health Management

C2.a Local priority Setting

C2.b Community engagement

C2.c Empanelment

C2.d Proactive population outreach

C. Service Delivery

Disruptive Innovations in US Primary Care: Overview and Digital Health Example Andy Ellner, MD, MSC Harvard Medical School Center for Primary Care Sean Duffy Omada Health

Potentially Disruptive Innovations in U.S. Primary Care

9 November, 2016 Andy Ellner, MD, MSc Director, Program in Global Primary Care and Social Change, HMS Assistant Professor of Medicine, Division of Global Health Equity, Brigham and Women’s Hospital

A disclosure

I am co-founder of Firefly Health, a company that is building a digital and care team platform to deliver better, safer primary care at large scale.

Ms. W

• 45 yo female, single, mother of two • History of abusive relationships • Works nights as housecleaner • Smokes and drinks alcohol above

recommended limits • Has depression and uncontrolled

diabetes and hypertension • Low engagement with medical treatment

Roadmap

• Global health systems in 2016 • The future of health systems innovation • Five potentially disruptive trends

Universal Health Coverage

Goal: eliminate financial hardship due to out of pocket expenditures on health services by providing financial risk protection Other important factors: • Strong health system • Robust healthcare

workforce • Supportive legislation

Deaths by cause and income

The neglected epidemic of chronic disease, The Lancet, Volume 366, Issue 9496, 29 October 2005-4 November 2005, Page 1514

The Crisis in Value

Health Care Expenditures and Life Expectancy in the United States and Ten Other Developed Countries SOURCE: V.R. Fuchs and A. Milstein | May 18, 2011 | DOI: 10.1056/NEJMp1104675

What determines health?

Schroeder, NEJM, 2007

Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.

Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2009

1% 5%

10%

50%

65%

22%

50%

97%

$90,061

$40,682

$26,767

$7,978

Annual mean expenditure

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%U.S. population Health expenditures

Re-thinking Health Spending

“Unlike virtually all other sectors of the U.S. economy, health care has experienced no gains over the past 20 years in labor productivity.”

Re-thinking Health Spending

Kocher and Sahni, NEJM, 2010

“Novel ideas, products, services, and processes—including new ways to promote healthy behaviors and better integrate health services with public health and other social services—which achieve better health outcomes and/or patient experience at equal or lower cost.”

Defining health systems innovation

Ellner et al, Acad Med, 2015

The Evolution of Health Systems

Time and Income Level

Disease Burden Acute Chronic

Health system orientation

React and rescue

Engage and empower

Technical excellence

Working within/leading

teams and systems

Passive Active

Key provider competencies

Role of ‘patient’

What does the future of primary care look like?

A Simple Framework for Re-orienting Care

1. Person 2. Place 3. Time

IT better communication, coordination, support and data

Financing aligned with value

Trend 1: Capitated or global payment

Trend 2: Non-visit Care

Virtual visit Triage E-consult

Trend 3: Task sharing

Customer Relationship Management

“Patients” Non-MDs

Clinical Protocols

Trend 4: Big data and Artificial Intelligence

Predicting risk Improving Diagnosis

Trend 5: Behavioral health

Behavior Change Depression

Ms. W

Smartphone app:

• Gives access to and control over health information

• Supports her around her health goals

1. Reducing smoking and alcohol

2. Managing her diabetes and hypertension

• Gives easy access to her care team for virtual care

Ms. W

Primary Health Care team • Health coaches reach out to her twice a year to check in • Nurses, supported by protocols and technology, provide most

basic acute and chronic care • Generalist physicians, with virtual support from specialist

consultants, triage high-acuity/complexity presentations and provide much of complex care virtually

• Psychologist or social worker helps with depression

Thank you!