Transformation in Patient Care: The PatientCentered Medical Home

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Transformation in Patient CareThe
Patient-Centered Medical Home

• Association for Prevention Teaching and Research
• February 2009

Michael S. Barr, MD, MBA, FACP Vice President,
Practice Advocacy Improvement Division of
Governmental Affairs Public Policy 202-261-4531
mbarr_at_acponline.org
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• Millions of our citizens do not now have a full
  measure of opportunity to achieve and enjoy good
  health. Millions do not have protection or
  security against the economic effects of
  sickness. The time has arrived for action to help
  them attain that opportunity and protection.

President Harry Truman Text from a speech he
delivered to a joint session of Congress in 1945
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State of the Nations Health Care
uninsured
employed
47 million 80 16 million 16.2 (2.2
trillion) 7,421
underinsured
of GDP
per capita in 2007
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Amenable Mortality 15th to 19th lt50 with access
to rapid appointment 75 difficulty with after
hours care 18 readmission rate within 30
days 100 billion
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Escalating Costs, Decreasing Coverage
Untreated illness work absence
130 billion 1500 vs. 450 vs. 150 70 to
60 98 vs. 23
Healthcare costs per U.S. auto vs. Germany Japan
Decreasing employer-sponsored coverage
Growth in premiums vs. inflation (00 07)
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125 million
U.S. population with 1 chronic condition
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157 million
By 2020
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Increasing Prevalence and Cost of Treated
Conditions in Medicare Beneficiaries
Data from Thorpe, K., Howard, D. Health Affairs
25 (2006) w378w388 10.1377/hlthaff.25.w378
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Annual Out-of-Pocket Spending per Person by
Chronic Conditions
Paez KA et al Health Affairs 28, no.1 (2009)
15-25
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17.615 Billion76
Medicare readmissions w/i 30 days
Annual cost
Potentially preventable
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2526,000
Medicare expenses that occur in the last year of
life
Beneficiary cost 6x survivors
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605,600 - 8,7002988 billion
Unwarranted variation in health care spending
Per capita South Dakota vs. Louisiana
Savings if
Potential expense reduction if
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• How can we fail to provide health insurance for
  16 of our population, deliver uneven quality to
  the 84 of Americans who are insured, and yet pay
  50 more per person than countries like France,
  Israel, and Britain, which cover all of their
  citizens?
• Ezekiel J. Emanuel, MD, PhDHealthcare,
  Guaranteed A Simple, Secure Solution for
  America, 2008

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PCMH Means

• to describe a pathway to excellent health care
• to re-claim a role as advocates for our patients
  (with our patients their families)
• to encourage team-based care
• to create educational opportunities
• to attract medical students and residents to
  primary care

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Team-based care
Links to Comm.
HIT
Self-Mgt
Evidence
System Design
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What is the Patient-Centered Medical Home?

• a vision of health care as it should be
• a framework for organizing systems of care at
  both the micro (practice) and macro (society)
  level
• a model to test, improve, and validate
• part of the health care reform agenda

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(Chronic) Care Model
Health System
Community
Health Care Organization
Resources and Policies
DeliverySystem Design
Decision Support
ClinicalInformationSystems
Self-Management Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
http//www.improvingchroniccare.org/index.php?pTh
e_Chronic_Care_Models2 Wagner EH. Chronic
disease management What will it take to improve
care for chronic illness? Effective Clinical
Practice. 1998 12-4.
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The Joint Principles of the PCMH
Team-based care NP/PA RN/LPN Medical
Assistant Office Staff Care Coordinator Nutritioni
st/Educator Pharmacist Behavioral Health Case
Manager Social Worker Community resources DM
companies Others

• Personal physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated and/or integrated
• Quality and safety
• Enhanced access to care
• Payment to support the PCMH

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National Priorities Partnership

• Engage patients families in managing their
  health and making decisions about their care.
• Improve the health of the population
• Improve the safety reliability of Americas
  healthcare system.
• Ensure patients receive well-coordinated care
  within and across all healthcare organizations,
  settings and levels of care.
• Guarantee appropriate compassionate care for
  patients with life-limiting illnesses.
• Eliminate overuse while ensuring the delivery of
  appropriate care.

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Core of Team-Based Care
NP/PA RN/LPN Medical Assistant Office Staff Care
Coordinator Nutritionist/Educator Pharmacist Behav
ioral Health Case Manager Social Worker Community
resources DM companies Others
Caregivers Immediate family Extended
family Friends Neighbors
Practice
Family Team
Physician Patient
Adapted from Defining Primary Care An Interim
Report, Institute of Medicine 1994
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Teams

• Wikipedia definition A team comprises a group of
  people linked in a common purpose. Teams are
  especially appropriate for conducting tasks that
  are high in complexity and have many
  interdependent subtasks.
• Interdependent team
• no significant task can be accomplished without
  the help of any of the members
• within that team members typically specialize in
  different tasks, and
• the success of every individual is inextricably
  bound to the success of the whole team. No
  football player, no matter how talented, has ever
  won a game by playing alone.

Adapted from http//en.wikipedia.org/wiki/Team
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Collaborative Care

• Collaboration includes ongoing interdisciplinary
  communication regarding the care of individuals
  and populations of patients in order to promote
  quality and cost-effective care
• Critical to ensuring that all patients receive
  the highest possible quality of care

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Required Ingredients

• Patient capable of sharing in medical decisions
• Prepared, well-organized health care team
• Practice to level of license, skill, ability no
  lower
• High technology high touch
• Organizational support
• Resources

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Building the Medical Home

• Collaboration
• Recognition
• Demonstration
• Advocacy
• Education
• Education
• Education

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Important Questions

• How do you recognize a PCMH?
• What does it cost and how will I be paid?
• Will it improve quality and reduce cost?
• Will patients be satisfied?
• How do we prepare physicians, students
  residents?

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NCQA Physician Practice Connections/PCMH

• Access Communication
• Patient Tracking Registry Functions
• Care Management
• Patient Self-Management Support
• Electronic Prescribing

• Test Tracking
• Referral Tracking
• Performance Reporting Improvement
• Advanced Electronic Communication

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Stepping Up to Excellence
Level 3 75 Points
Level 2 50-74 Points
Level 1 25-49 Points
Increasing Complexity of Services
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Level 1 25-49 Points

• Demonstrates timely access and communication
  processes
• Organizes charts (paper or electronic) to
  facilitate team-based care and tracking
  age-appropriate and condition-specific
  interventions
• Identifies key clinical conditions among
  population served follows evidence-based
  guidelines

• Encourages and provides support for
  patient/family self-management
• Addresses health literacy issues
• Tracks tests referrals to assure completion
• Collects and reports on quality satisfaction
  data to practice

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Key Points for Level 1 PCMH

• Does not require electronic health record
• Will require registry tracking functions
• Emphasis is on providing better care through
• Access to care
• Organization of office structure processes
• Enhancing patient self-management addressing
  health literacy issues
• Introduction of evidence-based guidelines,
  measurement quality improvement

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Practice Implications

• Need to understand challenges of transformation
• Initial capital and restructuring costs
• Ongoing support maintenance
• Reporting on quality, cost and satisfaction
• Implementation of HIT coincident with PCMH

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The Need for Education Support

• Team-based care
• Everyone practices to the level of his/her
  license, skill, and ability and no lower
• Patient-centered care
• Communication skills
• Use of technology
• Quality improvement measurement skills

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Growing Interest in the PCMH

• Patient-Centered Primary Care Collaborative
• 300 organizations represent 50 million people
• www.pcpcc.net
• Articles in NEJM, JAMA, Health Affairs, Annals
  of Internal Medicine
• Trade Lay Press
• Legislation
• New entrepreneurs

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A Commitment to Excellence

• Patient-centered communication
• Shared decision making
• Timely access to care
• Electronic health records
• Use of comparative effectiveness research
  evidence-based guidelines
• Measure, improve, measure
• Transparency accountability
• Safety