Less Tinkering, More Transforming:

Transcription

1 Less Tinkering, More Transforming: How to Build Successful Patient- Centered Medical Homes David Margolius 1

2 Disclosures 2

3 Outline I. What is primary care? II. What is the current problem with primary care? III. Is the Patient-Centered Medical Home movement going to fix it? IV. What does transformed primary care look like? 3

4 What is Primary Care? When countries at the same level of economic development are compared, those where health care is organized around the tenets of primary health care produce a higher level of health for the same investment. World Health Organization. The World Health Report 2008: Primary Health Care Now More Than Ever Geneva, Switzerland, World Health Organization 4

5 Optimal healthcare system design... 5

6 3 Care 3 Care 2 Care 2 Care 1 Care 1 Care 6

7 Our healthcare system.. 7

8 What is Primary Care? Barbara Starfield: 4 pillars of primary care First-Contact Continuous Coordinated Comprehensive Starfield B. Primary care: balancing health needs, services, and technology. New York (NY): Oxford University Press;

9 First-Contact Care From 5PM to 9AM 29% of U.S. primary care practices offered afterhours services compared with 97% in the Netherlands. Researchers telephoning U.S. primary care practices after hours found that 58% of calls went to answering machine at 5 PM Please call 911 if this is an emergency. Margolius D, Bodenheimer T. Redesigning After-Hours Primary Care. Ann Intern Med. 2011;155: Schoen C et al. A survey of primary care physicians in eleven countries, 2009: perspectives on care, costs, and experiences. Health Aff (Millwood). 2009; 28:w Hildebrandt DE et al. After-hours telephone triage affects patient safety. J Fam Pract. 2003; 52:

10 Continuity of Care Leads to better outcomes, including improved delivery of preventive care, fewer hospitalizations, reduced costs, and lower overall mortality.* Coordinated Care Press MJ. N Engl J Med 2014;371: Comprehensive Care Providers in the U.S. are more likely to refer to specialists than other wealthy countries.** *Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med. 2005;3(2): Wolinsky FD et al. Continuity of care with a primary care physician and mortality in older adults. J Gerontol A Biol Sci Med Sci. 2010;65(4): **Starfield B et al. Ambulatory specialist use by nonhospitalized patients in us health plans: correlates and consequences. J Ambulatory Care Manage ;32(3):

11 What is the Problem? A primary care physician with an panel of 2500 average patients will spend 7.4 hours per day doing recommended preventive care. Yarnall et al. Am J Public Health 2003;93:635 A primary care physician with an panel of 2500 average patients will spend 10.6 hours per day doing recommended chronic care. Ostbye et al. Annals of Fam Med 2005;3:209 11

12 First-Contact Care Too many patients for one provider? 2025 Hours (average hrs worked per yr by PCP) 983 Patients 2.06 Hours (average time per pt needed for preventive, chronic, acute care per year) Average panel size: 2500 patients Altschuler J, Margolius D, Grumbach K, Bodenheimer T. Ann Fam Med 2012;10: Alexander GC et al. J Gen Intern Med. 2005; 20 (12):

13 Why Primary Care? Does just any primary care produce a higher level of health for the same investment? And how are we gonna pay for it??? How do we create robust primary care which does achieve the Quadruple Aim: better health, better patient experience, lower costs, better staff experience? Bodenheimer T, Sinsky C. From Triple to Quadruple Aim. Ann Fam Med. Nov/Dec Vol 12, No 6. 13

14 Outline I. What is primary care? II. What is the current problem with primary care? III. Is the Patient-Centered Medical Home movement going to fix it? IV. What does transformed primary care look like? 14

15 A New Hope? The Patient-Centered Medical Home In 2007, major primary care professional groups crafted the concept of the PCMH. endorsements from Fortune 500 businesses, labor organizations, major national health plans, specialist societies, and the AMA. Personal Provider Enhanced Access Whole-Patient Orientation Safety/ Quality Payment Reform Coordinated and Integrated Care Continuity of Care Rittenhouse DR, Shortell SM. The patientcentered medical home: will it stand the test of health reform? JAMA J Am Med Assoc ;301(19):

16 PCMH: Criteria 16

17 PCMH: Here to Stay? Edwards S, Bitton A, Hong J, Landon B. Health Affairs, 33, no.10 (2014):

18 PCMH: Headlines last year 18

19 PCMH: Does it work? Ann Intern Med. 2013;158: PCMH may improve care experience for patients and staff? PCMH may improve care processes, especially for preventive service (ie did patients get colorectal cancer screening?) Maybe reduces ED visits for some high-risk patients. Insufficient evidence to comment on utilization, hospitalizations, ED visits otherwise. 19

20 PCMH: Results The intervention must include 2 of the following 4 elements: Enhanced Access to Care, Coordinated Care, Comprehensiveness, and a systems-based approach to improving quality and safety. 20

21 PCMH: NCQA Criteria 21

22 PCMH: NCQA Criteria 22

23 Example Same-Day Scheduling Policy

24 PCMH: NCQA Criteria 24

25 PCMH: What does it all mean? If tinkering around the edges can get you this what s the point? Where do we go from here? And how are we gonna pay for it??? 25

26 PCMH: What does it all mean? 26

27 PCMH: Here to Stay Edwards S, Bitton A, Hong J, Landon B. Health Affairs, 33, no.10 (2014):

28 PCMH: NCQA Criteria 28

29 Outline I. What is primary care? II. What is the current problem with primary care? III. Is the Patient-Centered Medical Home movement going to fix it? IV. What does transformed primary care look like? 29

30 First-Contact Care Too many patients for one provider? 2025 Hours (average hrs worked per yr by PCP) 983 Patients 2.06 Hours (average PCP time per pt needed for preventive, chronic, acute care per year) Average panel size: 2500 patients Altschuler J, Margolius D, Grumbach K, Bodenheimer T. Ann Fam Med 2012;10: Alexander GC et al. J Gen Intern Med. 2005; 20 (12):

31 Team-Based Care: From I to We 2025 Hours (average hrs worked per yr by PCP) 1947 Patients 1.04 Hours (average PCP time per pt needed for preventive, chronic, acute care per year) Most preventive and chronic care delivery can be shared with the team Altschuler J, Margolius D, Grumbach K, Bodenheimer T. Ann Fam Med 2012;10: Alexander GC et al. J Gen Intern Med. 2005; 20 (12):

32 Hypertension: The Old Way Mr. P s blood pressure is 155/95. Plan: Re-check at next visit in 2 weeks- 3 months. Mr. P s blood pressure is 155/95. Plan: Discuss diet and exercise? Start med? Mr. P s blood pressure is 155/95. Call Pharmacy: Mr. P never picked up med. 32

33 Hypertension: The Transformed Way Mr. P s blood pressure is 155/95. Plan health coach Health coach uses teach-back with home blood pressure cuff. Mr. P tells health coach he wants to try medication after seeing that his home BPs are high as well. Health coach starts BP med off of standing order Mr. P achieves action plan, BP now 135/85 Margolius D et al. Health Coaching to Improve Hypertension Treatment in a Low-Income, Minority 33 Population. Ann Fam Med May-Jun;10(3):

34 How we take care of our panel (PAST) 15-minute visit 15-minute visit Talk to specialist 15-minute visit 15-minute visit 15-minute visit 15-minute visit 15-minute visit 15-minute visit Visit hospital Return phone message 15-minute visit 15-minute visit 15-minute visit 15-minute visit 15-minute visit 15-minute visit 20% of work in primary care is done between visits. Farber et al. Ann Intern Med. 2007; 147:

35 How we take care of our panel (Transformed) Panel management Panel manager systematically reviews panels of patients to detect clinical quality performance gaps. Phone visits s Health coaches Health coaches give patients the knowledge, skills, and confidence to self-manage their chronic conditions. 30-minute visits Coordinate with team members Coordinate with specialists Nurse care managers Nurse care managers coordinate health care for certain high-needs groups. Group visit 35

36 Template of the Present Time Primary care physician Medical assistant 1 RN Nurse Practitioner Medical Assistant 2 8:00 Patient A Patient A Triage Patient H Patient H 8:10 Patient B Patient B Patient I Patient I 8:30 Patient C Patient C Patient J Patient J 9:00 Patient D Patient D Patient K Patient K 9:30 Patient E Patient E Patient L Patient L 10:00 Patient F Patient F Patient M Patient M 10:30 Patient G Patient G Patient N Patient N 36

37 Template of the Past Future Time 8:00 8:10 8:30 9:00 9:30 10:00 10:30 Primary care physician Patient A Patient E-visits B and Patient phone C visits Medical assistant 1 Patient Complex D patient Patient Complex E patient Coordinate with Patient F hospitalists and specialists Huddle Patient with G RN, NP Patient A Patient B Patient C Patient D Patient E Assist BP with Patient F coaching clinic Patient G RN Triage Huddle Nurse Practitioner Patient H Patient Acute I Patients Patient J Patient K Patient E-visits L and phone visits Patient M Huddle with Patient MDN Medical Assistant 2 Patient H Patient I Patient J Patient K RN Care management Panel management Panel management Patient L Patient M Patient N 30 patients are seen or contacted in the first 3 hours of the day 37

38 Group Health Olympia Multnomah County Health Dept Clinic Ole Sebastopol Community Health La Clinica de la Raza High-Performing Primary Univ of Utah- Redstone Care: Site Visits Allina Clinica Family Health Services Fairview Rosemont Clinic Mayo Red Center Medical Associates Clinic Mercy Clinics ThedCare Quincy, Office of the Future Cleveland Clinic- Strongsville Harvard Vanguard Medford Martin s Point- Evergreen Woods Newport News Family Practice Brigham and Women s Hospital North Shore Physicians Group West Los Angeles- VA South Central Foundation Who does what? How do they do it? Where do they do it? Sinsky C et al. In search of joy in practice Ann Fam Med May-Jun;11(3):272-8.

39 10 Building Blocks of High-Performing Primary Care Bodenheimer et al. Ann Fam Med March/April 2014 vol. 12 no

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45 How do we build successful Patient- Centered Medical Homes? We need a vision for transformation (must be beyond NCQA PCMH criteria). Rethink how we measure productivity (payers will move away from the fee-for-visit, when will our managers?). This is a long journey plan for and celebrate short-term wins. 45