The Doctor is In! Best Practices in

Medical Home JourneyAngelo P. Giardino, MD, PhD, MPH

Medical DirectorTexas Children’s Health PlanClinical Professor, Pediatrics

Baylor College of Medicine

A discrepancy between what we know and how we practice 2003 RAND study“Half of patients don’t get right thing done”

• 55% “right things” done for preventive services• 54% right things for acute care• 56% for chronic care• 79% for cataracts• 11% for alcoholism

McGlynn EA, et al. The Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine 2003; 348;26:2635-45.

Quality Mismatch - Adults

Quality Mismatch - ChildrenA discrepancy between what we know

and how we practice 2007 RAND study“Half of patients don’t get right thing done”

• 47% “right things” done for indicated care• 68% right things for acute care• 54% for chronic care• 41% for preventive• 92% for upper respiratory tract infections• 35% for preventive services for adolescents

Mangione-Smith, R. et al. The Quality of Ambulatory Care Delivered to Children in the United States. New England Journal of Medicine 2007;357;15:1515-1523.

The Goal

A Team Approach To Care

Shared Responsibility for Quality and Cost

Fostering A Culture Of Improvement

Medical Home Capabilities

• Team approach to care• Registries for the top few diagnoses• Pro-active care coordination• Quality systems and measurement built in• Partnership with community resources• Advanced patient education and self

management support• Service orientation• Information technology support

Care Coordination

• Using the registry to assure that everyone on the list gets the indicated care on a timely basis

• This is a team responsibility not an FTE

• Arrange appointments, follow-up, lab and educational opportunities

• Standing orders

Quality Systems Built In

• Flow sheets, reminders and checklists• Collect data for clinical measures at

the time of care• Use nationally endorsed measures• Report the data for comparison

purposes• Use the data to drive process

improvement in the office microsystem

Community Resources

• Disease specific educational or support services

• Engaging family and caregiver support

• Partnering with disease management programs provided by health plans

• Home care services when necessary

Time Spent on Care Coordination

PCP<1%

(87)

Office Staff15%(3118)Other

4%756

Care Coordinators76% (15,496)

Social Worker5%(951)

020406080

100120140160180200220240260280

1900 1920 1940 1960 1980 2000 2004

From Overpeck (7) From AMA

Total Physicians and FP/GP per 100,000 Population

TotalTotal physiciansphysicians

FP/GPFP/GP

300

From Silver (2)

American Academy of Family Practitioners

0

10

20

30

40

50

60

GP/FP

GIM

G Ped

G Sur

GOB

Physicians per 100,000 Population — 2000 (Total MD’s)

00--0-2,499 2,500--

4,999

5,000--

9,999

10,000--

24,999

25,000--

49,999

50,000--

199,999

200,000--

999,999

1,000,000--

2,999,999 3,000,000+

Ph

ysic

ian

s p

er

100,

000

Population Size Of The Community

Rural Small Town Suburban Urban

American Academy of Family Practitioners

The Primary Care PhysicianNumber of Office Visits to Primary Care Physicians vs. Other Specialists1

0

100

200

300

400

500

Fami ly/ General

Practi ce

Internal

Medicine

Pediatr i cs Al l Pr imary

Care

Other

Special i sts

208 Million

146 Million

117 Million

471 Million 440

Million

23% 16% 13%

52%48%

American Academy of Family Practitioners

Characteristics of Practices in Transformation

•Successful• Positive attitude• True sense of team• Process mapping• Systematic

approach• All participate and

are respected for their contribution

•Stuck in the mud

• Victim vocabulary• Command and

control• Wondering why• Just trying harder• Physicians

unapproachableAmerican Academy of Family Practitioners

ReferencesMcGlynn EA, et al. The Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine 2003; 348;26:2635-45.

Mangione-Smith, R. et al. The Quality of Ambulatory Care Delivered to Children in the United States. New England Journal of Medicine 2007;357;15:1515-1523.