Slides - University of Utah - School of Medicine

WHAT ABOUT THE
PATIENT-CENTERED
MEDICAL HOME AND
YOUR PRACTICE IN
2013?
Leslie Lenert MD
Associate Chair for Quality and Innovation
Department of Medicine
University of Utah Health Care System
What can we
do to get ready
for Medical
Homes and
Accountable
Care
Organizations?

THE PROBLEM WITH PRIMARY
CARE
Time for chronic disease
care for an average
patient panel:
- 10 hours per day
Time for preventative
care an average panel:
- 7.4 hours per day
Proportion of
recommended care
received by patients:
-! 55%

THE ARCHETYPE FOR PRIMARY CARE
REMAINS IN THE ROCKWELL ERA
We like it this way and people are willing to pay
for this type of personal attention
(e.g., Concierge or Retainer Medicine)

PARADIGM SHIFT:
PRIMARY CARE AS A SYSTEM
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Thomas Bodenheimer
4

MEDICAL HOME MODEL
Payment Reform
(pay for episode of
care, for
coordination of care)
Enhanced Access
(email, extend
hours, decision aids)
Personal
Physician
Quality and Safety
(evidence based medicine
perspective, use of IT to
facilitate quality and
assessment of quality)
Physician Directed Care
(practice team led by physician)
Whole Person
Orientation
Integration
(bring together all
services needed to
address a medical
issue)
5

MEDICAL HOME DESIDERATA
!! Personal physician.
!! Each patient has an ongoing relationship with a personal physician who is trained
to provide first contact, continuous and comprehensive care.
!! Physician-directed medical practice.
!! The personal physician leads a team of individuals at the practice level who
collectively take responsibility for ongoing patient care.
!! Whole-person orientation.
!! The personal physician is responsible for providing all of the patient’s health care
needs or for arranging care with other qualified professionals.
!! Care is coordinated and integrated
!! across all elements of the complex health care system and the patient’s
community.
!! Quality and safety are hallmarks
!! Enhanced access to care
!! Open scheduling, expanded hours and other innovative options for communication
between patients, their personal physician and practice staff.
!! Payment recognizes the added value
!! Practices that achieve NCQA’s PCMH Recognition are positioned to take
advantage of financial incentives

PCMH is a high level
strategy to change
the structure of primary care
Cost neutral
(Reductions in
ED and
Hospitalization)
Only feasible with cooperation
payers and health delivery systems
Raise income
levels and
supply of
primary care
providers
Continue to
reimburse for
services
Viable
primary
care
Add
reimbursement for
episodes of care
and pay for
performance
Add
reimbursement for
coordination of
care
7

WHY FOCUS ON THE MEDICAL HOME
MODEL
!! Improve patient experience
!! Improve quality of care
!! Reduce costs of care
!! Address issues with lack of satisfaction with practice, viability
of primary care as a specialty
!! Address income gap between specialists and primary care
physicians

HEALTHCARE IS A COMPLEX
ADAPTIVE SYSTEM

WHAT THIS MIGHT (EVENTUALLY)
MEAN FOR PHYSICIANS…
!! Team leadership role may predominate over personal
physician role
!! Larger panel sizes in some models (more team
leadership);
!! Smaller panel sizes in other models (more personal care
at a cost)
!! High severity of illness practices
!! Retainer practices
!! Empowerment for responsibility for patient outcomes
•! Payment for population health management and care
coordination services
•! At risk payment (Accountable Care Organizations)

OVERLAP BETWEEN PCMH AND ACO’S
!! Accountable Care Organizations (ACO) are provider-based
organizations that take responsibility for meeting the health
care needs of a defined population, with the goal of
simultaneously improving health, improving patient
experience and reducing per capita costs.
!! ! Determine and update care coordination needs
!! ! Create a a plan of care
!! ! Communicate
!! ! between health professionals and family
! !! within teams teams of health professionals
! !! Across health care settings
! !! Facilitate transitions
ACO
! !! Connect with community resources
! !! Align resources to population needs
PCMH

EFFECT ON QUALITY/OUTCOMES/COSTS
!! Wide evidence that PCMH improves quality metrics
Benefits of Implementing the Primary Care Patient- Centered Medical Home. Patient Centered Primary Care Collaborative
!! Early evidence that it improves outcomes
!! Geisinger: PCMH participation reduced patients risk of amputation
and renal failure. American Journal of Medical Quality 2012 27: 210
!! Some evidence it reduces costs
!! UMPC: -$15 PMPM HEALTH AFFAIRS 31, NO. 11 (2012): 2423–2431
!! Geisinger: -4% costs of care, ROI = ~1 Am J Manag Care. 2012;18(3):149-155)
!! Group Health: - $10 PMPM HEALTH AFFAIRS 29, NO. 5 (2010): 835-843

PCMH EFFECTS: OTHER VARIABLES
!! Operational costs increased by PMCH
!! $2 per PMPM cost for 10% gain in PCMH features JAMA. 2012;308(1):60-66
!! $6 PMPM total for UPMC pilot HEALTH AFFAIRS 31, NO. 11 (2012): 2423–2431
!! Total PCMH score not associated with patient satisfaction
Health Services Research DOI: 10.1111/j.1475-6773.2012.01429.x
!! Total PCMH score in Safety-Net clinics associated with
!! Improved provider and staff morale
!! Improved clinic staff job satisfaction
!! Less risk of burn out symptoms in providers
Arch Intern Med 2012;172(1):23-31

COMMON PROBLEMS WITH PCMH AS
SEEN BY PHYSICIANS ADOPTING IT
The Policy Context of Patient Centered Medical Homes:
Perspectives of Primary Care Providers
J Gen Intern Med DOI: 10.1007/s11606-012-2135-0

NCQA MEDICAL HOME CERTIFICATION
!! PPC-1: Written standards for
patient access and communication
!! PPC-1b: Use of data to show
standards for patient access and
communication are met
!! PCC-2D: Use of paper or electronic
tools to organize clinical
information
!! PPC-2E: Use of data to identify
important diagnoses and conditions
in practice.
!! PPC-3A: Adoption and
implementation of evidence-based
guidelines for three conditions.
Level 1: 50% of items
Level 2 or 3: 100% of items
!! PPC-4B: Active support of patient
self management
!! PPC-6A: System tracking of tests
and follow up of test results
!! PPC-7A: System tracking of critical
referrals
!! PPC-8A: Measurement of clinical
and/or service performance
!! PPC-8C: Performance reporting by
physicians across the practice

Medical-Home
Capacities
Improved access and
communication
Use of data systems to
enhance safety and
reliability
Care management and
coordination
Support for patient selfcare
Performance reporting
and improvement
How Capacities Are Measured in NCQA Certification
Program
Have written standards for key components of access and
communication (4 points) and use data to document how standards
are met (5). Assess language preference and communication
barriers (2). (Total: 11 points)
Use data system for nonclinical (2) and clinical (6) information to
track patients’ diagnoses (4) and clinical status (6) and to generate
reminders (3). Track referrals (4) and laboratory results
systematically (7). Use electronic system to order, retrieve, and flag
tests (6); write prescriptions (3) and check their safety (3) and cost
(2); and improve safety and communication (4). (Total: 50 points)
Adopt and implement evidence-based guidelines (3) and use
reminders for preventive services (4). Coordinate care with other
providers (5) and use non physician staff to manage patient care (3).
(Total: 15 points)
Develop individualized patient care plans, which assess progress
and address barriers to achieving plan goals (5). Actively support
patient self-care (4). (Total: 9 points)
Measure (3) and report performance to physicians in the practice (3)
using standardized measures (2). Report performance externally (1).
Survey patients about their experience (3). Set goals and take action

WHAT CAN WE DO TO MOVE TOWARD THE
MEDICAL HOME MODEL TODAY?
!! Micro level efforts (you and your patient)
!! Develop patient oriented goals and care plans
!! Activate patients and measure activation
!! Learn how to lead health care teams
!! Meso level efforts (organization of your clinic)
!! Written clinic policy development for medical home certification
!! Practice guidelines of conditions (pathways), tracking diagnostic test
orders as well as results
!! Panel management efforts
!! Macro level (fitting into the health system)
!! Retainer medicine practices
!! ACO development

Initial
office
visit
Time
Lab
visit
Lab
check
EXAMPLE OF A CARE PLAN
Pharmacy
Rx Pick up
Home
BP monitoring
Follow
up call
Lab
visit
Return
visit
“Plan: After checking a chemistry panel, we’ll start and ACE
inhibitor for hypertension. The patient will check his blood pressure
at home and we’ll call after two weeks to evaluate if he needs a dose
change. In 6 weeks he will return for a follow visit with a fasting lipid panel”

Measure Patient Activation (PAM)
Four stages of activation:
1.! Believes active role is
important
2.! Confidence and
knowledge to take action
3.! Taking action
4.! Staying the course
under stress
ED visits vs. activation
•! Stage 1: 24.1
•!
•!
Stage 2: 20.4
Stage 3: 17.9
P

LEARN HOW TO LEAD HEALTH CARE
TEAMS
Shared Values
!! Honesty: Put a high value on open
communication within the team, including
transparency about aims, decisions,
uncertainty, and mistakes.
!! Discipline. Carry out roles and responsibilities
even when inconvenient, and seek out and
share information to improve even when it is
uncomfortable.
!! Creativity: Be excited by the possibility of
tackling new or emerging problems, seeing
errors and unanticipated bad outcomes as
potential opportunities to learn and improve.
!! Humility: Recognize differences in training but
do not believe that 1 type of training or
perspective is uniformly superior; recognize
that team members are human and will make
mistakes.
!! Curiosity: Delight in seeking out and reflecting
on lessons learned and using those insights for
continuous improvement.
Principles
!! Clear Roles: Have clear expectations for each
member’s functions, responsibilities, and
accountabilities.
!! Mutual Trust: Earn each other’s trust,
creating strong norms of reciprocity and
greater opportunities for shared
achievement.
!! Effective Communication: Prioritize and
continuously refine communication skills
using consistent channels for candid and
complete communication.
!! Shared Goals: Work to establish shared goals
that reflect patient and family priorities and
that can be clearly articulated, understood,
and supported by all members.
!! Measurable Processes and Outcomes: Agree
on and implement timely feedback on
successes and failures in both the overall
functioning of the team and achievement of
specific goals.

MESOSTRATEGIES FROM GROUP HEALTH
COOPERATIVE
!! Virtual medicine
!! Secure email messaging and telephone
encounters
!! Chronic care management
!! Use of electronic registries, health maintainece reminders, best
practice alerts
!! Collaborative care plans
!! Self management resources, group visits, peer led workshops
!! Visit preparation
!! Patients contacted in advance of visits to clarify concerns and
expectations
!! Patient outreach
!! Outreach and follow up for all discharges, ED visits and urgent care
visits

PERSONNEL STRUCTURE OF A MEDICAL HOME
PRACTICE
Typical Medical
Office Staff
•!Medical Assistant
•!Biller
•!Scheduler
•!Office manager
•!Nurse call manager
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!! Order sets
for common conditions
USING YOUR EHR
!! Test and consult
completion

CHANGE IS HARD
•!Transformation to a PCMH “requires epic whole-practice reimagination
and redesign. It is much more than a series of
incremental changes”
•!Technology needed in a PCMH is not "plug and play.” The
hodge-podge of information technology marketed to primary
care practices resembles more a pile of jigsaw pieces than
components of an integrated and interoperable system.

MEDICAL HOME ALTERNATIVES
!! Retainer Medicine
!! Growing popularity
!! Per member – Per month fee provides access to additional resources
and limits panel sizes
!! Fees vary from $50 per month to $200 to ???
!! Panel size 600-1200
!! Allows personal attention and care coordination
!! Improves income or generates similar income with less effort
!! May reduce other costs
!! MDVIP members have 50% less utilization of hospital care
!! Rarely readmitted for MI, CHF, CAP (90% less often)
Personalized Preventive Care Leads to Significant Reductions in Hospital Utilization
Am J Manag Care. 2012;18(12):e453-e460
!! Difficult to fully adjust for effects of SES in this study

SUMMARY/CONCLUSIONS
!! Patient Centered Medical Home in 2013
!! New model for care
!! Transformatory but change is hard
!! Requires payer interest/participation
!! Evidence is growing for effects on
!! Quality of care ++++
!! Costs of care ++
!! Patient experience +/–
!! Physician burnout ++
!! Primary care salaries ?
!! Cost of transformation
!! $6-10 PMPM
!! IT integration is critical
!! Focus of the practice is on
!! execution of plans (as opposed to orders)
!! Behavioral change
Is it for me?