National Naval Medical Center: Integrated Medical Home CDR

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National Naval Medical Center Integrated Medical
Home

• CDR Kevin Dorrance, MD, FACP
• Sean Lynch, Program Manager

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The views expressed in this presentation are
those of the authors and do not necessarily
reflect the official policy or position of the
Department of the Navy, Department of Defense,
nor the U.S. Government.
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The Crisis in Perception(Health Care Survey of
DoD Beneficiaries)(Summer 2008)

• Less than 50 of Direct Care (MTF) beneficiaries
  believe they have a personal doctor
• Over 80 of purchased care beneficiaries believe
  they do.
• Consistent lags in the perception of effective
  communication in comparison of direct care system
  providers with others
• Consistent lags in the perception of respect,
  courtesy, and adequate time with provider by MTF
  users
• Consistent lags in the perception of finding
  appointments when needed in comparisons of the
  direct care system with civilian

Courtesy MHS PCMH Tiger Team
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Team-Based Healthcare Delivery

• Clinical Micropractice Groups
• Optimal personnel utilization
• Improved team communication
• Team leader with group responsibilities

Population Health
Access to Care

• Drives success measures
• Emphasis on preventive care and wellness
• Evidence-based medicine at the point of care

• Improved phone/electronic appts
• Open access for acute care
• Emphasis on coordination of care
• Proactive appointing
• chronic care
• prevention

Patients Families
Advanced IT Systems
Patient-Centered Care

• Secure e-communication
• Creation of education portal
• Reminders for preventive care
• Easy, efficient population health data tracking

• Active patient empowerment
• Encourage patient participation in process
  improvement
• Seamless communication
• Continuity focus

Patient-Centered Military Medical Home
Refocused Medical Training
Decision Support Tools

• Evidence-based training
• Integrated Clinical guidelines
• Decision support tools at point of care

• Patient-centered care design
• Health team leadership focus
• Evidence-based practice
• Focus on patient-centered quality indicators

Patient Physician Feedback

• Real-time data
• Performance reporting
• Patient feedback, satisfaction
• Patient-care team partnerships to improve care
  delivery

Model adapted from the NNMC Medical Home
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Lessons Learned Access

• Managing Artificial Demand
• Maximizes the value of the visit
• Efficient use of patients and providers time
• Improved communication
• Secure messaging
• Telephone

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Managing Artificial Demand The Result

• Improved access
• Open access for acute care
• 3rd Next available for routine care 1-2 days
• Increased time for comprehensive visit
• Reduction in specialty referrals by 40
• PCM continuity consistently gt80

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Lessons Learned Quality

• Episodic care is inadequate
• Proactive approach to population health
• Systems to support preventive and chronic care
• Patient needs assessed at every level an every
  interaction
• Partnership with other services
• Specialty schedules open for direct appointing
• Mammography service available same-day

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Proactive Population Health The Result
7/7 HEDIS Metrics gt90th percentile
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Lessons Learned Cost

• Variation in care must be addressed
• Mrs. White
• DM A1C 6.7
• LDL 86
• HDL 50
• BP 128/78

• Mr. Mustard (Ret Col)
• DM A1C 6.7
• LDL 80
• HDL 45
• BP 126/80

What's the difference in their care?
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The Cost!

• Mrs. White
• 48 / Month
• Glargine
• Glyburide
• Metformin
• Simvistatin
• HCTZ
• 28/ Month using NPH

• The COL
• 306 / Month
• Glargine
• Pramlintide
• Metformin
• Rosuvastatin
• Aliskrien

Why such a difference in management?
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Case Comparison

• Mrs. White is managed by a Family Physician
• The COL has a Specialist

Mrs. Whites Regimen is Support by Relevant
Medical Evidence!
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Current Health Care Model
Disease Disability
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Future Care ModelIntegrated Care

• Behavioral Health at the point of care
• Nutrition Therapists
• Self Management Program
• Mind Body Medicine Services
• Clinical Pharmacist

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Financial ROI
Better Quality Reduced Waste Lower Costs
Increasing lower-cost care reduces amount of
higher-cost care required
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Next Steps

• MHS Medical Home Policy Statement

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Discussion
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Redesigning Healthcare Delivery
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Resources

• http//www.bethesda.med.navy.mil/Patient/Health_Ca
  re/Medical_Services/Internal_Medicine/Medical_Home
  .aspx
• (or Google NNMC Medical Home)
• RADM Hunter Medical Home Podcast
• http//www.tricare.mil/PressRoom/Podcast.aspx

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Backup
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Return on Investment

• Costs Start-up and Ongoing
• Start-Up
• Staff Training (Self-management team concept)
• IT development
• Consultant for implementing shared appointments
• Renovations
• Ongoing
• IT maintenance
• Refresher Training
• New Extended Care Providers (Behavior
  Modification, e.g.)
• Additional staffing (compared to average MTF?)
• Other additional expenses to
• Improve Primary Care Access

• Expected Savings
• Changes in Utilization
• (An ounce of prevention)
• Fewer Hospitalizations ER Visits/Shorter Stays
• Will this translate into reduced operating
  expense staffing needs?
• Fewer redundant and unnecessary labs/tests/
  prescriptions
• Fewer episodes per patient and lower resource use
  per episode

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Return on Investment

• Difficult to quantify. Will take time.
• Benefits from disease/chronic management (reduced
  hospitalization, e.g.) are a long-term
  proposition.
• Staffing Is additional staffing a cost of MH
  implementation or not?
• (Compare to a standardized staffing model
  developed based on other MTFs/clinics?)
• Larger facilities may be able to capitalize on
  existing personnel and other infrastructure by
  reorganizing (Wellness/Population Health
  personnel, e.g.), more so than smaller
  facilities.
• Can realized savings be directly linked to MH
  implementation?