kevin t. rich, md, faafp | chief medical officer| family medicine residency of idaho, boise, idaho |...
TRANSCRIPT
Kevin T. Rich, MD, FAAFPChief Medical Officer| Family Medicine Residency of Idaho, Boise, IdahoAssociate Professor of Family Medicine | University of Washington SOM
Assistant Clinical Professor | Idaho State UniversityPast President | Idaho Academy of Family Physicians
Chair, Practice Transformation Committee| Idaho Medical Home CollaborativeChair, Regional Healthcare Collaborative | Idaho Healthcare Coalition
Patient Centered Medical Home28th Annual Idaho Conference on Health Care
8th Annual Thomas Geriatric Health Symposium October 2, 2015
PCMH in Idaho – What it is and What it will become
IN AN AVERAGE MONTH:
White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885-892.Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001;344:2021-2025
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PRIMARY CARE = QUALITY
PRIMARY CARE = LOWER COST
INCREASED GENERALIST CARE = HIGHER QUALITY
INCREASED GENERALIST CARE = LOWER COSTS
INCREASED SPECIALTY CARE = WORSE QUALITY
INCREASED SPECIALTY CARE = HIGHER COST
PATIENT CENTERED MEDICAL HOME
· Place
· Process
PATIENT CENTERED MEDICAL HOME NEIGHBORHOOD
RATIONALE FOR THE BENEFITS OF PRIMARY CARE FOR HEALTH Greater Access to Needed Services
Better Quality of Care
A Greater Focus on Prevention
Early Management of Health Problems
Cumulative Effect of Primary Care to more Appropriate Care
Reducing Unnecessary and Potentially Harmful Specialist Care
Source: Starfield B., Leiyu S., Mackinko J., Contribution of Primary Care to Health Systems and Health, (Milbank Quarterly, Vol. 83., No. 3, 2005) 457-501)
PATIENT CENTERED MEDICAL HOME
· Place· Process
PCMH: WHAT DOES IT LOOK LIKE IN PRACTICE? “Integrated and coordinated care with the patient at the center”
“A continuous relationship with a personal physician/physician team occurs, coordinating care for both wellness and illness.”
Fundamental principles: Improved access to care
Comprehensive care
Whole person orientation
Care management
Continuity of care
Team approach to care
Culture of quality and safety
Integration of health information technology to improve access to care, quality of care and patient safety.
PCMH DEFINITIONS/TERMINOLOGY
Standards NCQA
URAC
TransforMed
Change Concepts McColl Institute
SNMHI/Qualis
PCMH STANDARDS TransforMed Access to Care and
Information
Practice Services
Care Management
Continuity of Care Services
Practice-Based Care Team
Quality and Safety
Health Information Technology
Practice Management
· NCQA Enhance Access and
Continuity
Identify and Manage Patient Populations
Plan and Manage Care
Provide Self-Care Support and Community Resources
Track and Coordinate Care
Measure and Improve Performance
CHANGE CONCEPTS Engaged Leadership
Quality Improvement Strategy
Empanelment (linking each patient with a provider)
Continuous, Team-Based Healing Relationships
Patient-Centered Interactions
Organized, Evidence-Based Care
Enhanced Access
Care Coordination
MS. G Ms. G is a 48 yo single mother of three teenagers who does
domestic work.
She is underinsured and receives her care at a public hospital clinic.
BMI of 37, poorly controlled diabetes, elevated blood pressure and painful osteoarthritis of her knees.
Chronically depressed and has required opioids to control her knee pain. She frequently misses her doctor appointments, and the clinic suspects that she is not taking her medications (including opioids) as prescribed. Her depression seems to be unresponsive to meds, and her symptoms are making it harder for her to work.
Ms. G became increasingly fatigued and dyspneic, and was admitted in CHF.
MS. G’S MEDICAL CARE PER CHANGE CONCEPT
Enhanced Leadership
Leadership preoccupied with financial status*Ensure that the PCMH transformation effort has the time and resources needed to be successful.*Ensure that providers and other care team members have protected time to conduct activities beyond direct patient care that are consistent with the medical home model.
Quality Improvement Strategy
Performance measurement limited to required reports. Occasional QI projects.*Ensure that the PCMH transformation effort has the time and resources needed to be successful.*Ensure that providers and other care team members have protected time to conduct activities beyond direct patient care that are consistent with the medical home model. *Ensure that patients/family, providers, and care team members are involved in quality improvement activities
Empanelment No effort to link patients with primary care teams. Despite poor disease control and missed appointments, practice has never tired to initiate a visit.*Assign all pts’. a panel*Use panel data and registries to proactively contact and track patients
Continuity and Team-Based Care
She sees whoever has an appointment available that day. MD’s have no defined team.*Link patients to a provider and care team that are accountable to the care of pts. Define roles and distribute tasks among care team members
Organized Evidence-Based Care
Care delivered in brief, reactive visits. Her no-shows make it hard to titrate meds. No staff available to provide more intensive follow-up. *Identify high risk groups and ensure they get care needed;*Planned care visits;*Evidence-based POC reminders
Access No evening or weekend appointments make it difficult for her to work and keep appointments.*24/7 access via phone, email, *Open access scheduling
Coordination The clinic was unaware that she went to the ED with symptoms of CHF and was admitted. She was readmitted 3 weeks after discharge having had no outpatient care.*Follow up with patients within a few days of an emergency room visit or hospital discharge.*Communicate test results and care plans*Link pts. with community resources and communicate with referrals
Patient-Centered Interactions No trained self-management support. She often doesn’t understand what the MD’s tell her to do.*Post visit f/u- print or email care visit summaries*Care plans
TRANSFORMATION What is it?
Practice Redesign
Looking at a different way of delivering careo “Integrated and coordinated care with the patient at the center”o “A continuous relationship with a personal physician/physician team
occurs, coordinating care for both wellness and illness.” Fundamental principles:
Improved access to care Comprehensive care Whole person orientation Care management Continuity of care Team approach to care Culture of quality and safety Integration of health information technology to improve access to care,
quality of care and patient safety.
THE PCMH DATA-TO-DATE Excellent ROI
Geisinger Health Systems, Group Health Cooperative, MultiCare, Dean Health System, CCNC, IHC
Quality of Care, Patient Experiences, Care Coordination, and Patient Access all Improve
Decrease ER Utilization 15-50% (Avg. 30%)
Decrease Hospitalization 10-40% (Avg. 19%)
Decrease Cost/Patient $835-$1,750/Year
Increase Patient Satisfaction and Decrease Physician Burnout
THE FUTURE OF THE MEDICAL HOME IN IDAHO
WHAT IS THE SHIP?
The State Healthcare Innovation Plan (SHIP) is a
statewide plan to redesign our healthcare delivery
system, evolving from a volume-driven, fee for service
system to a outcome-based system that achieves the
triple aim of improved health, improved healthcare
and lower costs for all Idahoans.
IDAHO SHIP MODEL ELEMENTS Strong Primary Care System
Patient Centered Medical Homes (PCMH) – Foundational
Medical Neighborhood (Hospitals, Subspecialists, Others)
Regional Cooperatives (RC) Support Local Primary Care Providers and Medical Neighborhood
Statewide Idaho Healthcare Coalition (IHC)
IDAHO SHIP MODEL ELEMENTS Health Information is Linked Electronically by EHR
and HIT
Data Analytics
Payment Systems are Aligned Across Major Payers
Patient Engagement/Accountability
Transforms Public Health to Population Health
Regional Collaborative
Patient Centered Medical Home (PCMH)
Patient Centered Medical Home Neighborhood
Idaho Healthcare Coalition (IHC) / SHIP
IDAHO HEALTHCARE COALITION (IHC) MODEL TESTING GRANT $61M Grant (CMMI)
Notified November 5, 2014 – $40M
Four Years
Achieve Triple Aim: Better Health; Better Healthcare, Lower Costs
Projected Savings $89M/Three Years
ROI (197%) over Five Years
IHC MODEL TESTING GOALS 180 Primary Care Practices (PCMH’s) over Three Years
(900 PCP’s); 1.3M People (80%)
EHR/HIE Integration (PCMH / Neighborhood)
Build Seven Regional Collaboratives
75 Virtual PCMH’s (>550 CHW’s/CHEMS) / Telehealth
Data Analysis – Collecting, Analyzing, Reporting
Align Payment Mechanisms
IDAHO HEALTHCARE COALITION (SHIP) SUMMARY Vehicle and Model for Healthcare Transformation for Idaho
Built on Foundation of Primary Care and the Patient Centered Medical Home (PMCH)
Integrates and Coordinates the PCMH with Secondary Providers, Hospitals, and Other Members of Healthcare Team
Connects Public Health to Population Health Quality Metrics
Integrates Clinical and Claims Data
Aligns Payment Systems with Access and Outcomes
Transforms Health Care in Idaho Triple Aim
INTEGRATION· EMR· PCMH· PCMH
Neighborhood· Hospitals· ACO
SYMPHONY OF CARE
THE IMPORTANCE OF FM/PC AND THE PCMH TO IDAHO’S TRANSFORMING HEALTH CARE SYSTEM The Backbone
First Line of Care
Leverages Relationships, Continuity, Comprehensiveness
Focuses on Health
Integrates and Coordinates
Bridge to Other parts of the Health Care System when Needed
This is the Future of Health Care in Idaho
THE PCMH IN IDAHO TODAY AND TOMORROWTODAY
· Concept – Adolescence
· Implementation – Childhood
· Payment – Infancy
· Potential – Value-Add
TOMORROW
Adulthood
Adulthood
Young Adulthood
Tremendous Value-Add
QUESTIONS