The PCMH in Action: Successes, Challenges and Lessons Learned · The PCMH in Action: Successes,...
Transcript of The PCMH in Action: Successes, Challenges and Lessons Learned · The PCMH in Action: Successes,...
The PCMH in
Action:
Successes,
Challenges and
Lessons Learned
Darren M. Schulte, MD, MPPEVP, Collaborative Care Solutions, Alere
Digital Medical Office of the Future ConferenceLas Vegas, NevadaSeptember 10, 2010
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The Promise of the PCMHBenefits
Potential to strengthen primary care
Better coordinate and integrate patient care, esp for chronic disease
mgmt
Effectively incorporate HIT and evidence based decision support/
tracking tools into the practice
Early (qualified) success
Quality gains, increased patient and provider satisfaction
Lessons
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Healthy Primary Care = Quality Care
Multiple studies conducted over last several decades in
many countries report that greater access to primary care
results in:
* Fewer ED visits and hospital admits;
* More preventative treatment
* Lower overall costs
as compared with specialist driven care
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But Primary Care Is Under Stress…
Over next 5-10 years, more patients will seek primary care
given demographic trends and insurance reform
Without structural and payment reforms to attract and
retain generalists, access to quality primary care will
continue to suffer
Despite near universal coverage in Mass. following 2006
reform initiative, 20% of adult residents reported difficulty
obtaining care in 2009.1Sources:
(1) Health Affairs 2010: 29:6. 1234-1241
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Joint Principles of a PCMHMajor generalist societies (ACP, AAFP, AAP, AOA)
adopted principles for a medical home
1. Personal physician
2. Physician directed medical practice
3. Whole person orientation
4. Integrated, coordinated care
5. Quality and safety emphasis
6. Enhanced access
7. Payment reform 5
NCQA PPC-PCMH Recognition Standards
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Landscape of PCMH Initiatives
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• 27 multi-stakeholder projects in 20 states
• Single commercial payer sponsored projects in an
additional 21 states
• Medicaid / CHIP sponsored projects in 38 states
• There are only 5 states without any PCMH initiatives
underway
From Principles to Practice…
PCMH demonstration initiatives Hospital admits ER visits Total savings per pt
Colorado Medical Home for Children - 18% NR $215
Geisinger Health - 15% NR NR
Group Health Cooperative* - 6% -29% No change (initial 18mo)
$10 pmpm (>21 mo)
Intermountain Health Care -4.8% No change $640
North Carolina (CCNC) -40% ** -16% $516
North Dakota (MeritCare & BCBS ND) -6% -24% $530
Vermont Blueprint for Health -11% -12% $215
Sources: D. Fields, et. al. Health Affairs 2010; 29(5): 819-826; Grumbach, et. al. The Outcome of Implementing a Patient
Centered Medical Home Interventions. PCPCC Publication. Aug 2009 ; Reid, et al. Health Affairs 2010; 29 (5): 835-843
Annual Outcomes for Major Medical Home Demonstrations
Notes: *Compared with a control group; ** Asthma patient only. NR = not reported.
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What Were the Essentials for Success?
Dedicated care coordinators
Expanded provider access
Effective health information technology
• track patient issues, goals, recommended care
• predictive modeling, risk profiling, decision support
• performance measurement
Meaningful incentive payments
• Hybrid models – FFS plus coordination fees +/- performance-
Source: D. Fields, et. al. Health Affairs 2010;
29(5): 819-826
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Group Health Experience1
GHC piloted medical home pilot at Seattle in 2006
(total of 9,200 pts)
Reduced average physician panel size by ~25%
Hired more clinical and ancillary staff
Made greater use of virtual medicine, patient outreach
and chronic care mgmt techniques10
Group Health Experience (cont’d)
Results after 12 months…
• Improved patient satisfaction and access
• Reduced provider burnout
Positive experience based upon:
• Primary care investment for optimal staffing ratios
• Staff training and office workflow redesign
• Strong leadership and change management
• Use of patient-centric electronic records 11
It’s Harder than It Looks…A successful medical home will require:1
Physicians to work within (and lead) care teams
Expanded focus from one patient at a time to proactive practice panel
management
New practice organization and care delivery models
Active use of evidence-based decision-support, clinical registries and
information technology
Sources
(1) Ann Fam Med 2009;7:254-260.
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…And Physicians Aren’t Trained for This
Care team leadership
Continuous quality improvement
Population health management
Health coaching and education
Behavior change approaches
Patient self management skill building
Patient care goals and issue tracking & monitoring
Community resource integration13
Physicians & Coaches - Reinforcing Roles
Skill Set Physicians & Nurses* Health Coaches*
Provide Information Good Fair to Good
Stimulate Motivation Poor Good
Enhance Behavioral Skills Poor Good
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• Physicians have perceived their job to offer health advice and treat disease, not
motivate and change behavior
• Coaches are trained and expected to educate, build motivation and skills, and
provide support in order to help individuals achieve their goals
• Working together, each at the “top of their license”, clinicians and coaches can be
highly complementary and synergistic
* On average
Source:
Adapted from Gordon Norman, MD. Healthcare
Unbound Presentation, July 2010
Lessons from the National Demonstration
Project
Change is hard
• Integration of new roles, and responsibility into new
coordinated practice models with HIT adoption
• There is no simple “plug and play” technology focused
approach
Relationships matter
• Culture of teamwork and trust is critical to sustaining change
• Physicians must become team-focused
Leadership is key 15
It Takes a Village…Medical homes are not enough
without integration within a larger medical neighborhood
Care fragmentation between generalists and specialists will
mitigate PCMH gains
Most successful PCMH initiatives to date operate within an
integrated delivery network
Keys to success -- Information sharing, accepted
performance standards and incentives, and broad
accountability1
Source: N. Eng J Med 2008. 359(12): 1202-1205
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PatientCentered Care
Collaboration Opportunities
Smaller (and larger) practices will need assistance to
realize truly patient-centric care within a panel
PCMH providers who choose capable partners to provide
integrated support services and health information
connectivity will likely fare better than those who elect to
build it all themselves
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Technology Framework for the Medical Home
Steve Adams
What is a Medical Home?
• A model for care provided by physician practices that seeks to
strengthen the physician-patient relationship
• Replaces episodic care, based on illness and patient
complaints, with coordinated care, and a long-term, healing
relationship
• “Each patient has an ongoing relationship with a personal
physician who leads a team that takes collective responsibility
for patient care.”
• When needed, that physician arranges for appropriate care
with other qualified physicians
• Emphasizes enhanced care through open scheduling,
expanded hours, and communication between patients and
physicians
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PCMH Workflow
Practice must focus on individual and population level care
management.
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Functional Requirements
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Technology to Support PCMH
Practices may need to combine technology solutions
to meet all PCMH requirements.
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Meet Robert Amber
• Multiple comorbidities:
–Asthma
–Diabetes
–Hypertension
• His physician, Joseph
Barclay, MD, has made his
practice a Medical Home
• Dr. Barclay’s practice is part
of an IPA, where all the
practices participate in a
common care coordination
management platform
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Care Team
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Care Notes
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Messaging
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Messaging: Test Results
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Connected Clinical Registry
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Health Logs
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Summary
•The PCMH model requires care coordination &
interaction with an extended care team (not just the
physician)
•Solutions exist today to make PCMH work within a
practice
•Technology is one component of becoming a PCMH
practice – implementing the way the practice does
business is equally important
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