Medical Home: Primary Care for the 21stCenturyIs This the Path to Quality and Value in Health Care?
Louisiana Health Care Quality ForumMay 23, 2008
Richard C. Antonelli, MD, MS, FAAPAssoc Prof Pediatrics, Univ Conn SOM
Chief of General PediatricsConnecticut Children’s Medical CenterAAP National Center for Medical Home Initiatives Project Advisory Committee
Every System is Perfectly Designed to Get the Results it Gets
– Institute for Healthcare Improvement – National Initiative for Children’s Healthcare
Quality
Definition of Medical Home
• Care that is:– Accessible– Family-centered– Comprehensive– Continuous– Coordinated– Compassionate– Culturally-effective
Definition of Medical Home
• And for which the primary care provider shares responsibility with the family.
AAP/ AAFP/ NAPNAP/ ACP
Functional Definition of Medical Home
• Partnership between family and providers
• Commitment to continuous quality assessment and improvement
• Single point of entry to a “system” of care that facilitates access to medical and non-medical resources
Joint Principles of the PCMHAAP, AAFP, ACP, AOA
March 2007
• Whole person orientation• Personal physician • Physician directed medical practice• Care is coordinated and/or
integrated• Quality and safety• Enhanced access to care • Payment to support the PC-MH
Issues
• Can Primary Care Survive?– Capacity of current workforce
– Attracting new providers to workforce
• What About Quality and Value?• Do We Need Medical Home?
– Highest quality with least disparity to access occurs when Medical Home available
51
63
45
28
39
23
3238
50
0
25
50
75
100
Total Under 200% poverty 200% poverty or more
White African American Hispanic
Percent of adults ages 19–64 with health problems*
Figure 8. Across Income Levels, African Americans Are More Likely to Have Health Problems, Even After Adjusting for Age
* Defined as having any chronic condition or disability.Note: Percentages are age-adjusted.Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).
Lacking Health Insurance for Any Period Threatens Young Adults’ Access to Care, 2005
31
181112
17
54
42
283132
57
45353738
0
40
80
Did not fill a
prescription
Did not see
spec ialist when
needed
Skipped medical
test, treatment, or
follow-up
Had medical
problem, did not
see doctor or
c linic
Any of the four
access problems
Insured all year Insured now, time uninsured in past year Uninsured now
Percent of adults ages 19–29 reporting the following problems in the past year because of cost:
Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).
The Result of Delayed Access?
• More Expensive Care Rendered in Emergency Departments
• In case of Mental Health, services “rendered” in criminal justice system
17 13 1710
811
835
14
9
0
25
50
75
Total White African
American
Hispanic Asian
American
Uninsured now Insured now, time uninsured in past year
Percent of adults 18–64
2621
28
18
49*
Figure ES-1. Nearly Half of Hispanics and One of FourAfrican Americans Were Uninsured for All or Part of 2006
* Compared with whites, differences remain statistically significant after adjusting for income.Source: Commonwealth Fund 2006 Health Care Quality Survey.
20 9
5461 54
39
27 30 34
4512
16*
0
25
50
75
100
Total Insured all year,
income at or above
200% FPL
Insured all year,
income below
200% FPL
Any time
uninsured
Medical home
Regular source of care, not a medical home
No regular source of care/ER
Percent of adults 18–64
Figure ES-3. Uninsured Are Least Likely to Have aMedical Home and Many Do Not Have a Regular Source of Care
Note: Medical home includes having a regular provider or place of care, reporting nodifficulty contacting provider by phone or getting advice and medical care on weekendsor evenings, and always or often finding office visits well organized and running on time.* Compared with insured with income at or above 200% FPL, differences are statistically significant.Source: Commonwealth Fund 2006 Health Care Quality Survey.
74767474
50525352
343138
44
0
25
50
75
100
Total White African American Hispanic
Medical home
Regular source of care, not a medical home
No regular source of care/ER
Figure ES-4. Racial and Ethnic Differences in Getting Needed Medical Care Are Eliminated When Adults Have Medical Homes
Percent of adults 18–64 reporting alwaysgetting care they need when they need it
Note: Medical home includes having a regular provider or place of care, reporting nodifficulty contacting provider by phone or getting advice and medical care on weekendsor evenings, and always or often finding office visits well organized and running on time.Source: Commonwealth Fund 2006 Health Care Quality Survey.
Families of CSHCN will be partners in decision-making and are satisfied with the services they receive
2005-2006
Families of CSHCN will have adequate private and
public insurance to pay for the services they need 2005-2006
% of CSHCN whose family members cut back and/or stop working because of child's health needs
2005-2006
Primary Care Score vs. Health Care Expenditures, 1997
Starfield 06/02
US
NTH
CANAUS
SWEJAP
BEL FRGER
SP
DK
FIN
UK
0
0.5
1
1.5
2
1000 1500 2000 2500 3000 3500 4000
Per Capita Health Care Expenditures
Pri
ma
ry C
are
Sco
re
US
NTH
CANAUS
SWEJAP
BEL FRGER
SP
DK
FIN
UK
NZ
While access to insurance is an important and necessary determinant for having a Medical Home, it is not sufficient to predict quality of care or
outcomes.
Is Medical Home Enough?
• Transforming American Healthcare from a “Sector” to a “System” Requires Broad-based Re-design: – Financing– Quality measurement– Regulatory support– State and Federal policy support
• Infrastructure is Medical Home
Priority Areas for National Action: Transforming Health Care Quality
• Priorities Relating to Children and Youth– Care Coordination- across paradigms of care
– Self-management/ health literacy
– CSHCN
– Immunizations
– Depression
– Medication Management
Institute of Medicine
Functional and Clinical Outcomes
Resources and Policies
Community
Chronic Care Model (Wagner, et al)
Health System
Health Care Organization (Medical Home)
Delivery
SystemDesign
Decision
Support
ClinicalInformatio
nSystems
Care Partnership
Support
Informed,ActivatedPatient/Family
Prepared,ProactivePractice Team
Family -centered
Coordinated and EquitableTimely & efficient
Evidence-based & safe
Supportive, Integrated Community
Prepared,ProactivePractice Team
What is Care Coordination?
A process that facilitates the linkage of children and their families with appropriate services and resources in a coordinated effort to achieve good health.
AAP 2005
Care Coordination- ACP
• Ensuring communication among specialists and PCP and families
• Tracking if referrals happen
• System to prevent errors among multiple providers
• Tracking Test Results
Outcome Prevented – Aggregate Data Antonelli and Antonelli, Pediatrics 2004 The CCMT allows only one outcome prevented per encounter. 32% of total 3855 CC encounters prevented something. Of the 1232 CC Encounters where prevention was noted as an outcome: Outcome Prevented # CC Encounters Percentage Visit to Pediatric Office / Clinic 714 58% Emergency Department Visit 323 26% Subspecialist Visit 124 10% Hospitalization 47 4% Lab / X-Ray 16 1% Specialized Therapies 8 1% 62% of RN CC Encounters prevented something. 33% of MD CC Encounters prevented something. RNs are responsible for coding 81% of the Emergency Department preventions and 63% of the sick office visit preventions.
What Can Be Measured re: CC?
• Adult Medical Home– Screening rates for disease and risk factors– Screening for secondary disabilities– Presence of registry and its utilization– Development of Care Plans (these have CPT codes
already)– Mechanism for linkage from practice-based CC to
community-based CM– Training opportunities for CC’ers– ED and in-patient utilization for patients with chronic
conditions
What Can Be Measured re: CC?
• Pediatric Medical Home– Parent/ youth partners in QI at practice level– Developmental and behavioral screening– Screening for secondary disabilities (much less prevalent than
adult practice)– Presence of registry and its utilization– Development and deployment of Care Plans (these have CPT
codes already)– Mechanism for linkage from practice-based CC to community-
based CM– Training opportunities for CC’ers– ED and in-patient utilization for patients with chronic conditions
Stakeholders
• Families• Employers (Leapfrog Group, National Quality
Forum)• Providers• Community-Based Organizations• Payers: Medicaid and Commercial (PCPCC)• State and Federal Agencies• Legislators
National Noteworthy Models of Medical Home and Care
Coordination
• Minnesota Medicaid Transformation
• North Carolina
• PACE: case management/ CC for adults with chronic conditions
Useful Websites
• http://www.medicalhomeinfo.org: American Academy of Pediatrics hosted site that provides many useful tools and resources for families and providers
• http://www.medicalhomeimprovement.org: tools for assessing and improving quality of care delivery, including the Medical Home Index, and Medical Home Family Index
References
• McPherson, M., Arango, P., Fox, H., et al. (1998). A new definition of children with special health care needs. Pediatrics, 102,137–140
• U.S. Department of Health and Human Services. www.hhs.gov/newfreedom, accessed April 26, 2005
• Committee on Children with Disabilities, American Academy of Pediatrics. (2005). Care coordination policy statement
References (cont)
• Committee on Quality of Health Care in America, Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century
• Committee on Identifying Priority Areas for Quality Improvement, Institute of Medicine. (2003). Priority areas for national action: Transforming health care quality. Adams, K. and Corrigan, J. Editors.
• Providing a Medical Home:The Cost of Care Coordination Services in a Community-Based, General Pediatric Practice, Pediatrics, Supplement, May, 2004, Antonelli, R. and Antonelli, D.