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

What About Disparity?

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.

CSHCN receive coordinated, ongoing, comprehensive

care within a medical home 2005-2006

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

What Is Important About Primary Care?

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

What Is the Result of CC in a Pediatric Medical Home?

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

PCMH-PPC: NCQA, AAFP, ACP, AAP and AOAMedical Home Recognition Criteria

Linked to Reimbursement

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.