Medical Home: Primary Care for the 21stCentury Is This the Path to Quality and Value in Health Care

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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, FAAP
• Assoc Prof Pediatrics, Univ Conn SOM
• Chief of General Pediatrics
• Connecticut Childrens Medical Center
• AAP National Center for Medical Home Initiatives
  Project Advisory Committee

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Every System is Perfectly Designed to Get the
Results it Gets

• Institute for Healthcare Improvement
• National Initiative for Childrens Healthcare
  Quality

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Definition of Medical Home

• Care that is
• Accessible
• Family-centered
• Comprehensive
• Continuous
• Coordinated
• Compassionate
• Culturally-effective

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Definition of Medical Home

• And for which the primary care provider shares
  responsibility with the family.
• AAP/ AAFP/ NAPNAP/ ACP
  

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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

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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

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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

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What About Disparity?
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Figure 8. Across Income Levels, African Americans
Are More Likely to Have Health Problems, Even
After Adjusting for Age
Percent of adults ages 1964 with health problems
Defined as having any chronic condition or
disability. Note Percentages are
age-adjusted. Source The Commonwealth Fund
Biennial Health Insurance Survey (2005).
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Lacking Health Insurance for Any Period
Threatens Young Adults Access to Care, 2005
Source The Commonwealth Fund Biennial Health
Insurance Survey (2005).
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The Result of Delayed Access?

• More Expensive Care Rendered in Emergency
  Departments
• In case of Mental Health, services rendered in
  criminal justice system

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Figure ES-1. Nearly Half of Hispanics and One of
FourAfrican Americans Were Uninsured for All or
Part of 2006
Percent of adults 1864
49
28
26
21
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Compared with whites, differences remain
statistically significant after adjusting for
income. Source Commonwealth Fund 2006 Health
Care Quality Survey.
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Figure ES-3. Uninsured Are Least Likely to Have
a Medical Home and Many Do Not Have a Regular
Source of Care
Percent of adults 1864
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.
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Figure ES-4. Racial and Ethnic Differences in
Getting Needed Medical Care Are Eliminated When
Adults Have Medical Homes
Percent of adults 1864 reporting always getting
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.
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CSHCN receive coordinated, ongoing, comprehensive
care within a medical home 2005-2006
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Families of CSHCN will be partners in
decision-making and are satisfied with the
services they receive 2005-2006
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Families of CSHCN will have adequate private and
public insurance to pay for the services they
need 2005-2006
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of CSHCN whose family members cut back and/or
stop working because of child's health needs
2005-2006
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What Is Important About Primary Care?
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Primary Care Score vs. Health Care Expenditures,
1997
Starfield 06/02
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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.
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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

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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

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Chronic Care Model (Wagner, et al)
Supportive, Integrated Community
Informed, Activated Patient/Family
Prepared, Proactive Practice Team
Prepared, Proactive Practice Team
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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

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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

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What Is the Result of CC in a Pediatric Medical
Home?
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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 CCers
• ED and in-patient utilization for patients with
  chronic conditions

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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 CCers
• ED and in-patient utilization for patients with
  chronic conditions

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Stakeholders

• Families
• Employers (Leapfrog Group, National Quality
  Forum)
• Providers
• Community-Based Organizations
• Payers Medicaid and Commercial (PCPCC)
• State and Federal Agencies
• Legislators

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

• Linked to Reimbursement

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National Noteworthy Models of Medical Home and
Care Coordination

• Minnesota Medicaid Transformation
• North Carolina
• PACE case management/ CC for adults with
  chronic conditions

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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

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References

• McPherson, M., Arango, P., Fox, H., et al.
  (1998). A new definition of children with special
  health care needs. Pediatrics, 102,137140
• 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

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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 HomeThe Cost of Care
  Coordination Services in a Community-Based,
  General Pediatric Practice, Pediatrics,
  Supplement, May, 2004, Antonelli, R. and
  Antonelli, D.