HIV and Primary Care Transformation baltimore 5 21
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HIV and Primary Care Transformation: RWCA and the PCMH
Steve Bromer, MD
Department of Family and Community Medicine
UCSF
Goals Why does the US healthcare system need the
PCMH? Why should RWCA clinics transform into
PCMHs? What is the PCMH model and how close are
RWCA clinics to it?
ARS: What role do you play in your clinic?
Provider (Physician or Mid-level) Medical Assistant Front Office Administrator RN Social Worker Pharmacist Other
ARS: My practice setting
Primary Care Practice with HIV Care referred out
Primary care practice with integrated HIV program
HIV Specialty Practice with integrated primary care
HIV Specialty Practice with Primary Care referred out
ARS: Choose the reason
A. To learn more about the Patient Centered Medical Home (PCMH) as a way to transform our practice
B. To learn more about the details of becoming accredited/recognized as a PCMH
C. My boss made me come and Baltimore is a cool city
D. To learn about how concepts from the PCMH apply to multiply diagnosed populations
ARS: Choose the statement you agree with most:
HIV patients need excellent HIV specialty care and primary care is not as important for good outcomes
HIV patients need excellent primary care and the HIV specialty care is not as important for good outcomes
Both HIV Specialty care and primary care are important for good outcomes
With today’s medications, HIV patients will do well regardless of the quality of their healthcare
Mortality Amenable to Health Care
7681
88 84 89 8999 97
8897
109 106116 115 113
130 134128
115
65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110
0
50
100
150
Fran
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pan
Austra
liaSpa
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lyCan
ada
Norw
ayNet
herla
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Swed
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Ger
man
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Zea
land
Denm
ark
Unite
d Kin
gdom
Irela
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tuga
l
Unite
d Sta
tes
1997/98 2002/03Deaths per 100,000 population*
* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.
Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.
Abundant research evidence indicates that health systems and regions with a strong foundation of primary care have:
Better population health outcomes Better quality of care More preventive care Lower costs More equitable care and mitigation of health
disparities
Primary Care Strength and Premature Mortality in 18 OECD Countries
*Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R2(within)=0.77.
Source: Macinko et al, Health Serv Res 2003; 38:831-65.
Year
High PC Countries*
Low PC Countries*
10000
PYLL
1970 1980 1990 2000
0
5000
Source: Baicker & Chandra, Health Affairs, April 7, 2004
Source: Baicker & Chandra, Health Affairs, April 7, 2004
first ContactComprehensiveContinuityCoordination
A Functional Definition of Primary Care:Barbara Starfield Framework
But the Primary Care Foundationin the US is Crumbling Plummeting numbers of
new physicians entering primary care and burnout among PCPs
Growing problems of access to primary care and “medical homelessness”
Dysfunctional systems that are not delivering the goods in primary care
ARS: Approximately what percentage of adults report difficulty getting a prompt appointment, phone advice, or night/weekend care without going to the ER? 10% 25% 50% 75% 90%
ARS: What is the average time before patients are interrupted when making initial statements to their primary care physician?
2 seconds 23 seconds 58 seconds 98 seconds 120 seconds
ARS: What percentage of patients leave the office visit without understanding what their physician said?
10% 25% 50% 75% 90%
73% of adults surveyed reported difficulty getting a prompt appointment, phone advice, or night/weekend care without going to the ER. Public views on of US health system organization, Commonwealth Fund, 2008
23 seconds: Average time before patients were interrupted when making initial statement of their problem to their primary care physician. Marvel et al. JAMA 1999;281:283
50% of patients leave the office visit without understanding what their physician said. Schillinger et al. Arch Intern Med 2003;163:83
20
Poor clinician/patient relationships
ARS: What percentage of people in the US with HTN are poorly controlled?
10% 25% 50% 75% 90%
Inconsistent Quality• What percent of people in the US have poorly controlled
Hypertension? Diabetes? 25%, 50%, 75%?? Cholesterol?
50% of people with hypertension, 80% of people with high cholesterol, 43% of people with diabetes are poorly controlled.
Egan et al. JAMA 2010; 303(20):2043-2050, Ford, Internat’l J Cardiol 2010;140:226, Cheung et al. Am J Med 2009;122:443
The problem: panel sizes too large for primary care physicians to manage alone A primary care physician with an panel of 2500
average patients will spend 7.4 hours per day doing recommended preventive care. Yarnall et al. Am J Public Health 2003;93:635
A primary care physician with an panel of 2500 average patients will spend 10.6 hours per day doing recommended chronic care. Ostbye et al. Annals of Fam Med 2005;3:209
23
Average panel size in the US is 2300 patients Alexander et al. J Gen Intern Med 2005; 20:1079-83.
Recognition That Reform and Revitalization of Primary Care is Essential for ACA and Health Care Reform to Achieve Its Goals
The President Wants More and Stronger Primary Care
“It used to be that most of us had a family doctor; you would consult with that family doctor; they knew your history, they knew your family, they knew your children, they helped deliver babies. How do we get more primary physicians, number one; and number two, how do we give them more power so that they are the hub around which a patient-centered medical system exists, right? ” June 8, 2010, Town Hall with Seniors
Senator Orrin HatchSenate Finance Committee RoundtableReforming America’s Health Care Delivery System April 21, 2009
“The US is first in providing rescue care, but this care has little or no impact on the general population. We must put more focus on primary care and preventive medicine. How do we transform the system to do this?”
Randy MacDonald, Sr VP House Ways and Means Hearing April 29, 2009
“I will start with the very last question asked by the committee--what is the single most important thing to fix in healthcare? Primary care. Strengthen primary care -- transform it and pay differently using a model like the Patient Centered Medical Home.”
Congressman: “And the second issue?”
“Well, if you don't fix the first issue and do not have a foundation of powerful primary care then you can do nothing else. You have to fix primary care before you can even begin to address a second issue.”
A 20th Primary Care Model Will Not Meet the Demands of 21st Century!
Ryan White: an Unintentional Home Builder “An unintended consequence…. of the RW Care
Act has been the establishment of the comprehensive delivery of multiple services for patients with a complex disease….medical homes for the HIV-infected person…..”
“The act created in his (Ryan White’s) memory, unintentionally created medical homes that are the best examples of how all of us should receive primary care.”
Saag, M. The AIDS Reader, April 24, 2009
Quality: Cervical Cancer
Screening: 60% Oral Health Exam: 36% ARV regimens with no
contraindications: 85.6%
Workforce The Looming Crisis in HIV Care: Who Will Provide the Care?
“In a survey conducted by HIVMA and the Forum for Collaborative HIV Research, a majority of Ryan White Part C-funded programs reported increasing caseloads and serious challenges recruiting and retaining HIV clinicians.
Reimbursement and a lack of qualified providers were the top two barriers cited.”
HIV Medicine Association, 2010
ARSWorkforce: How long have you worked in the HIV/AIDS field?
1. This is my first year
2. 1-5 years
3. 5-10 years
4. 10-15 years
5. 15-20 years
6. More than 20 years
Funding:
HIV Medical Homes Resource Center
Click icon to add picture
Vital Signs: HIV Prevention Through Care and Treatment -- United States. MMWR December 2, 2011/60(47);1618-1623
Engagement in HIV Care
Will a 20th Century Model of HIV CareMeet the Demands of the 21st Century Epidemic?
Joint Principles of the Patient Centered Medical Home February 2007
American Academy of Family Physicians American Academy of Pediatrics American College of Physicians
American Osteopathic Association
Transforming the Delivery of Primary Care:The Patient Centered Medical Home
Ongoing Relationship with provider for first-contact, continuous, and comprehensive care;
Health Care Team that collectively cares for the patient;
Whole-person Orientation, including acute, chronic, preventive, and end-of-life care;
Coordinated Care across all elements of the health care system and the patient’s community;
Transforming the Delivery of Primary Care:The Patient Centered Medical Home
Quality and Safety through evidence-based medicine and clinical decision-support tools, information technology, registries, and continuous quality improvement;
Enhanced Access, achieved through such systems as open scheduling, expanded hours, and new options for communication between patients, their physician, and practice staff; and
Payment Reform to reflect the added value that a PCMH provides to patients.
HIV Medical Homes Resource Center
Continuous
First Contact
Comprehensive
Coordinated
Delivery System DesignClinical IS/HITDecision SupportSelf-ManagementCommunity ResourcesProactive TeamsActivated Patients
PatientCentered Medical
Home
Evidence on Value of New Primary Care Models: Case Study of Group Health Cooperative of Puget Sound
Patient Centered Medical Home model piloted at one site in 2007
Avg PCP panel size reduced from 2327 to 1800 Longer face-to-face visits and scheduled time
for phone and email encounters Increased team staffing and teamwork HIT Panel management
Group Health PCMH Pilot:Controlled Evaluation 12 Month Outcomes
Improved continuity of care Better patient experiences (6 of 7 measures) Better composite quality of care score Reductions in ED visits and Ambulatory Care
Sensitive Hospitalizations No difference in total costs at year 1 (lower total
costs by year 2)
Source: R Reid et al. Am J Managed Care 2009;15:e71
Group Health PCMH Pilot:Effect on Clinic Staff
Control Sites PCMH Site0%
5%
10%
15%
20%
25%
30%
35%
40%
34.5%
30.0%
33.3%
9.7%
Baseline
12 Months
Percent with High Level Emotional
Exhaustion
p=.02
Change Concepts for the PCMH
Engaged Leadership Quality Improvement Strategy Empanelment Continuous and Team-based Healing Relationship Organized, Evidence-Based Care Patient-Centered Interactions Enhanced Access Care Coordination
Wagner, EH et al, Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes; February, 2012
The Building Blocks of High-Performing Primary Care: lessons from the field
23 high-performing practices Intensive visits to 7 West Coast practices Discussions with and observations of
clinicians, RNs, MAs, front desk, leaders High-performing practices look about the
same, with variation in the details 10 building blocks -- the foundation of these
practices
Willard R, Bodenheimer T: CHCF April 2012
Building Blocks of High-Performing Primary Care:Share-the-CareTM Model
Change Concepts Building Blocks NCQA Recognition
Engaged Leadership Data for Improvement Enhance Access/Continuity
Quality Improvement Strategy
Empanelment, Panel size management
Identify/Manage Patient Populations
Empanelment Team-based Care Plan/Manage Care
Continuous and Team-based Healing Relationships
Population Management Provide Self-Care Support/Community Resources
Organized Evidence-based Care
Continuity of Care Track/Coordinate Care
Patient-Centered Interaction Prompt Access to Care Measure/Improve Performance
Enhanced Access Expanded Access Template
Care Coordination Mission with objectives and goals
Care coordination with Medical Neighborhood
Trained Leaders
HIV Medical Homes Resource Center
DATA/Quality Improvement Strategy
Change Concepts
Building Blocks
?Ryan White
Formal QI processDefined metricsOptimized HIT
Robust data collectionReporting systems to share data Strategic decisions about metrics
Are we Data Driven organizations?Do we use real-time data on important clinical/operational data to guide day-to-day actions?
Grant requirement to have CQI, robust metrics, early adopter of registry, variable HIT capacity
HIV Medical Homes Resource Center
Empanelment
Change Concepts
Building Blocks?
Ryan WhitePrioritizes patients seeing own PCP Clear denominator at panel level
Empanelment not specific grant requirement, often happens because of structure of practice
Is empanelment a deliberate process where we can use provider panels for quality data , proactive care and to actively manage supply and demand?
Assign all patients to provider panelBalance supply and demandUse panel data to manage population
HIV Medical Homes Resource Center
Team-Based Care
Change Concepts
Building Blocks?
Ryan White
Patients are connected to a Care TeamRoles/tasks defined
Culture shift to share-the-care. Flexible, functional teams, with clearly defined roles
Multi-disciplinary Teams are central to RWCA
Are our teams organized around getting the work done with an explicit vision and clear principles? With defined workflows, skills training and ground rules?
Team-based Care
Why does team-based care matter? Align roles to meet
population needs
Build capacity to make timely access possible
Non-clinician team-members contribute to continuous healing relationship
Foundation for the Template of the future
4. Team-based Care
Traditional Methods of Managing Work Flow
Provider
Chronic Disease
Monitoring
Preventive Med
Intervention
Mental Health Provider
Referral to Specialist
after Assessment
Medication Refill
New Acute Complaint
Certified Medical
Assistant
Case Manager
Test Results
HealthcareSupport Team
Team-based care
• Culture shift: share the care
Stable teamlets
• Co-location
Staffing ratios
Standing orders/protocols
• Defined workflows and roles – workflow mapping
• Training, skills checks, and cross training
• Ground rules
• Communication – healthy huddles, terrific team meetings and constant conversation
Team-based care: stable teamlets
Patientpanel
1 team, 3 teamlets
Clinician/MAteamlet
Patientpanel
Clinician/MAteamlet
Patientpanel
Clinician/MAteamlet
Health coach, behavioral health professional, social worker, RN, pharmacist, panel manager, complex care manager
HIV Medical Homes Resource Center
Prompt Access to Care
Change Concepts
Building Blocks?
Ryan White
24/7 access to care team, patient-centered scheduling options, address barriers to access
Balance supply and demand, open access, multiple channels of access
Do we have a patient-centered approach to access?
After hours coverage, +/- use of advanced access tools
http://www.careinnovations.org/knowledge-center/knowledge-centerwest-county-health-center-video/
HIV Medical Homes Resource Center
Population Management/Panel Management
Change Concepts
Building Blocks
?Ryan White
Plan care according to need, manage high-risk patients, point-of-care reminders
Robust population management, Self-management, Complex Case management, planned visits
Case Management key feature of RWCA, client level data, self-management support
Are we able to focus at the population level and proactively assign resources where needed? Is data used in day-to-day care?
HIV Medical Homes Resource Center
Care Coordination
Change Concepts
Building Blocks Ryan White
Link patient with community resources, referral tracking, coordination of specialty care
Management of care transitions, behavioral health services, communication of results
Comprehensive model of care, often under one-roof, expectation that transitions are tracked
?How good are we at managing the care that happens outside of our four walls?
HIV Medical Homes Resource Center
Conscious Trained Leadership/Values and Mission Statement
HIV Infecte
d
HIV Diagnose
d
Linke
d to HIV Care
Retained in
HIV Care
On ART
Suppresse
d Viral L
oad0
102030405060708090
100
Series 3Series 2Series 1
Vital Signs: HIV Prevention Through Care and Treatment -- United States. MMWR December 2, 2011/60(47);1618-1623
Engagement in HIV Care
=Access =Care Co-ordination =Population Management
A
P
A
AA
A
C
C
CC
PP
P
HIV Medical Homes Resource Center
Summary
Both Primary Care and the RWCA are at a crossroad
PCMH is one model of transformation RWCA clinics have many components of PCMH There is much to learn from PCMH model and
high performing primary care Our health care system will have to change to
meet our goal of an AIDS Free Generation
Roadmap for Medical Home Resource Center
PCMH concepts in RWCA Clinics– Action
Planning
Change Management of Improvement Opportunities
PCMH Certification
Strategic Planning Workshops
TA and Virtual Learning Community for practice change
TA to support certification
Year 1 Year 2 Year 3