Making Medical Homes Work: from Concept to Practice Measurement Opportunities

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Making Medical Homes Work from Concept to
PracticeMeasurement Opportunities Potential
Pitfalls
PCPCC Center for Multi-stakeholder Demonstrations
--Call Series  

• Ann S. OMalley, MD, MPH
• Deborah Peikes, PhD
• Hoangmai Pham, MD, MPH
• Paul Ginsburg PhD
• Myles Maxfield, PhD

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Outline of Presentation

• Overview
• Introduction
• Why we need to avoid running ourselves over
• Primary Care Principles
• Considerations in MH Measurement
• Qualification Phase
• Potential Pitfalls
• Evaluation Phase

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Sister organizations

• Center for Studying Health System Change (HSC)
• Independent policy research organization in D.C.
• Design and conduct studies on U.S. health care
  system
• Foundation-funded and government grants
• Mathematica Policy Research (MPR)
• Primarily contract research objective, range of
  expertise
• Federal, foundation and state program evaluations
• MPR and HSC helped with Medicare Med Home
  demonstration design other Medical Home pilots

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1st of 4 Presentations

• March 10- Matching Patients to a Medical Home
• Debbie Peikes, PhD (MPR)
• April 7- Paying for Medical Homes
• Hoangmai Pham, MD, MPH (HSC)
• May 5- The Information Exchange Challenge
• Myles Maxfield, PhD (MPR)

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1. Overview- Medical Home

• Little written to date on moving from theoretical
  concept to practical application of medical
  home
• What would an effective medical home program look
  like?
• How should it be implemented?

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Save us from ourselves!

• Charging ahead without sufficient consideration
  of feasibility, design and measurement issues
  risks alienating patients and providers
• Risk of overpromising given short term pilots
• Effective change takes time
• Do not want to jeopardize the political viability
  of the primary care model, in particular
  improving its availability and quality (potential
  for irony)

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Primary Care

• Central organizing principle of effective health
  care systems
• Associated with better outcomes in international
  and state-by-state comparisons
• Medical Home builds on the primary care concept
• (WHO Millis 1966, Alpert 1974 Parker 1974
  American Academy of Pediatrics, Starfield 1992
  Institute of Medicine 1996 Joint Principles
  Document on PCMH)

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Primary Care Medical Home

• Accessible (First contact care)- point of entry
  for each new problem
• Continuous-ongoing care over time
• Comprehensive- provides or arranges for
  services across all of patients healthcare
  needs
• Coordinated- integration of care across a
  persons conditions, providers settings and
  with patients family and caregivers and
  community
• (Starfield, IOM and others)

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Chronic Care Model

• Patient self-management support
• Clinical information systems
• Delivery system redesign
• Decision support
• Health care organization
• Community resources
• These 3 aspects in particular, used in
  combination have improved single condition care,
  i.e. diabetes
• (Wagner 2001 Tsai 2005)

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2. Measurement

• Qualification phase (Criteria--Capabilities)
• Evaluation phase
• During the demonstrations/pilots (uptake,
  feasibility, processes, whats changing in the
  practices, patients and providers reactions and
  experiences)
• At the end of the demonstrations/pilots

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Measures as Guideposts

• Qualification measures serve as a guideposts to
  practices on where to focus their improvement
  efforts toward becoming medical homes
• Therefore, important that these measures capture
  the essence of what it means to be a primary care
  medical home

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Identifying MH Measures

• Validity-captures the primary care concepts
• Evidence that measure is associated with improved
  processes and outcomes for patients
• Feasible-not overly burdensome for practices
• Triangulate- Ideally, incorporate patient,
  provider and clinical data on both processes and
  outcomes
• Achievement rather than mere potential

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Qualification Phase What to measure?

• Structures and Processes need to provide
• Accessible first contact care
• Continuity
• Coordination
• Comprehensiveness
• Appropriate use of IT-e.g. Registry, EMR
• Team functioning
• Pre- and Post-visit planning
• Quality safety tools for EBM, decision support,
  QI
• Patient centeredness (ask the patient)

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Accessible first contact care

• Structure (Capacity)
• Accessibility
• Geographic access
• Phone access
• Appointment making ease
• Same day appointment capability
• After hours care availability and 24x7 coverage
• Communication
• PCMH Qualification Tool should demonstrate that
  these capacities exist
• Process (Performance)
• Utilization
• Ideally measured at population level to capture
  those without good access-but for PCMH at a
  minimum, patient input important here
• At practice level, can measure extent to which
  first visit for a new problem occurred at the
  PCMH-assess visit/claims data

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Continuity over time

• Structure (Capacity)
• Patient List/Registry
• Mutual recognition of the PCMH by both parties
  
• Patient
• PC-MH team
• Process (Performance)
• Extent to which patients care occurs at the PCMH
  for all problems except for those for which a
  referral is indicated
• Personal relationship over time
• Examples of Measures
• of patient visits that occurred at the PCMH
• of patient visits that were with the same
  practitioner

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Comprehensiveness

• Structure (Capacity)
• Range of Services Available at PCMH
• Provides services to meet all common health needs
• Clinically indicated care based on age, needs and
  complexities
• Preventive, Acute, Basic Procedures, Ongoing care
  for Chronic Conditions
• Ability to arrange for services too uncommon for
  PCMH to provide
• Process (Performance)
• Recognition of Patient Needs
• Utilization
• Chart audits/records provided by facility as to
  delivery of services
• Information on types of problems and diagnoses
  seen
• Extent to which care occurs in the PCMH vs gets
  referred out

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Coordination of care

• Structure (Capacity)
• Continuity
• Either visit continuity with a qualified
  practitioner, or
• Medical record continuity of information from
  visit to visit
• Ideally, both are present
• Process (Performance)
• Problem Recognition
• Information on the status of problems is noted
  from previous visits, including information on
  care received outside of the PCMH, in a way that
  gets recognized by the patients personal
  physician/PC-MH team at the current visit.
• Referrals are coordinated and tracked by PC-MH

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Additional Measures of

• Appropriate use of IT- e.g. Registry, EMR
• Team functioning
• Pre- and Post-visit planning
• Quality safety tools for EBM, decision support
  , QI
• Patient centeredness (ask the patient)
• These support provision of accessible,
  continuous, coordinated and comprehensive care
• Quality measures can continue to be collected
  (e.g. HEDIS measures) during demo and compared
  between the intervention and comparison groups

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Potential Measurement Pitfalls

• Risk of overemphasizing things that are easier
  to measure, i.e. IT, single condition care, or
  things not specific to PC
• Risk of underemphasizing the defining PC
  features accessibility, continuity,
  coordination, comprehensiveness
• Potential for misqualification of practices
• Miss some of the good primary care practices if
  they have fewer IT features
• Include others that may have IT structures in
  place but not deliver continuous, coordinated
  comprehensive care

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Evaluation Measures

• How practices provide medical home services
• Learning opportunity on provider and patient
  acceptance, feasibility of different supports and
  care processes
• Process and outcome measures
• Process measures where evidence is strong that
  certain processes are associated with improved
  clinical outcomes, to ensure we capture short
  term effects

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Evaluation Measures

• Impacts of medical home services on
• Utilization (ex. Hospitalizations, ED visits,
  spec visits etc)
• Quality-of-care and health outcomes
• Physician and practices - satisfaction, work
  flow, costs,
  revenue, profits
• Patients and their familiescare experience, in
  particular whether their care is accessible,
  continuous, coordinated and comprehensive
• Costs (across all services)