AAMC Readiness for Reform

Transcription

1 Innovations in Access Duke Medicine: Primary Care Capacity Building Learn Serve Lead Association of American Medical Colleges

2 The AAMC launched the Readiness for Reform (R4R) initiative in 2010 to support the nation s medical schools and teaching hospitals as they implement key elements of health care reform. R4R began with a voluntary institutionwide survey to assess members level of preparedness for eight key focus areas of health reform: education, research/comparative effectiveness, payment reform, care delivery reform, community and patient engagement, access, quality, and health information technology (HIT). The AAMC now supports a number of projects aimed at identifying and sharing best practices related to the R4R focus areas in member institutions. More information on the R4R initiative can be found at: This case study is one in a series that will highlight member success stories in the eight R4R focus areas. AAMC Readiness for Reform Case Study Project Team: Joanne Conroy, M.D. Chief Health Care Officer AAMC Michael Weitekamp, M.D. Robert G. Petersdorf Scholar-in- Residence AAMC Meaghan Quinn Senior Program Specialist AAMC Tom Enders Managing Director Manatt Health Solutions Molly Smith Manager Manatt Health Solutions Carl Mankowitz, M.D. Senior Advisor Manatt Health Solutions The following individuals from Duke School of Medicine contributed to this case study: J. Lloyd Michener, M.D. Chair, Department of Community and Family Medicine Duke School of Medicine John Anderson, M.D., M.P.H. Chief Medical Officer Duke Primary Care Michelle Lyn, M.B.A., M.H.A. Division Chief of Community Health Department of Community and Family Medicine Duke School of Medicine Elizabeth Long Chief Operating Officer Duke Primary Care Barbara S. Sheline, M.D. Assistant Dean for Primary Care Duke School of Medicine Edward Buckley, M.D. Vice Dean for Medical Education Duke School of Medicine

3 Background Duke University, like many top-tier academic health centers, has a reputation for offering cuttingedge clinical care, with a national and global reputation for excellence in research. What is lessknown about Duke, however, is the story of how the university through strategic investment, community engagement, and information technology has built a primary care system that is increasingly coordinated and integrated throughout both the health system and the communities it serves. The story is instructive for other academic medical centers as they prepare for the opportunities and changes brought about by the Affordable Care Act. Duke s experience illustrates how primary and specialty care can work in harmony both inside and outside the walls of an academic medical center. After the demise of capitation systems, many health care systems divested from primary care. Duke did not. Instead, Duke continued to support and expand its primary care system, doubling it in size over the last five years making it one of the largest primary care networks in the state. It currently comprises 140 providers at 26 different practices in seven counties who see a combined 500,000 patients annually. It operates as an integral part of the health system, includes stakeholders across both the university and the community, relies heavily on investments in electronic medical records, and is now transitioning from an almost pure focus on patient care to a broader role in education and research, including recruitment and retention of physician assistants, nurses, care managers and other members of the primary care team working at the top of their training. Five factors are behind Duke s success: building trust with the community, diversifying the primary care portfolio, integrating research, investing in primary care education, and leveraging information technology. While Duke and its community are unusual in many ways, the success factors detailed in this paper can be replicated in many other academic medical centers (AMCs) across the nation as they navigate changes in the wake of health reform. Five Sucess Factors for Duke s Primary Care Development Build Trust with the Community Diversify the Primary Care Portfolio Integrate Research Goals Invest in Primary Care Education Leverage Information Technology 3

4 Factor 1: Build trusting relationships with the community Duke s modern history with community engagement began in 1996, when leadership and faculty of the Duke Department of Community and Family Medicine and the School of Nursing worked with the leadership of Durham County s Health and Social Services Departments, the local federally qualified health center (FQHC), and its then-rival hospital, Durham Regional Hospital, to initiate a series of discussions about improving the health of Durham s low-income populations. Uncontrolled asthma emerged as a major issue for community and clinical partners, and all of the partners donated time and support to create a common program to improve asthma outcomes. In addition to the financial support offered by Duke, the group found funding from a local foundation. The process of building a common vision and collaborative interactions was not easy. But eventually, partners were able to describe the elements of a successful collaboration and faculty sought out possible topics and programs to consider on the basis of those elements. An office of community relations was established in 2002 by the chancellor and the CEO of Duke University Health System. The Office of Community Relations and the Department of Community and Family Medicine worked together with other members of the university to enhance the positive experiences that members of the community have with Duke University Health System. Under the leadership of the Office of Community Relations, a committee of Duke and Durham representatives early on identified a common set of Principles of Community Engagement, which have guided the work together: Any proposed projects at Duke should be based on a need identified by the community that is beneficial to the community. The scope and time frame of the project should be clear to the community. Partners must be willing to commit time and resources to the project. Partners must trust each other and build mutual respect while learning from each other s perspectives. A diverse range of community members and agencies need to participate to ensure that proposed activities meet the needs of a diverse population. All participants are considered experts. A safe environment must exist for all participants of all backgrounds to share ideas without fear of ridicule or criticism. No blaming or judgments. Keep lines of communication open. Partners must be good stewards of project data and include the community in outcome reporting and evaluation, potential programmatic intervention, education opportunities, and future program planning activities. During the last 15 years, the shared initiatives between Duke and Durham have expanded to include a wide array of clinical, care management, health promotion, and disease prevention programs. With numerous operating programs providing low-cost clinical services for more than 11,000 patients, care management programs serving 60,000 patients, and chronic disease 4

5 prevention reduction programs serving more than 100,000 people, Duke has fully established a model of community health that reduces unnecessary hospitalizations, improves health outcomes and strengthens relationships between the AMC and the community. Factor 2: Diversify the primary care portfolio The secret of success in Duke s overall primary care system lies in the breadth of programs it coordinates both inside and outside of Duke s health campus. A wide range of clinical services is offered, and services are tailored to the needs of the groups served, from small nurse, or physician assistant (PA)-run clinics in schools and neighborhoods, to large primary care practices that offer one-stop service for almost all needs. Clinics are continually assessed and redesigned to improve services, especially for the most disadvantaged and hard to reach community members. Specific highlights of the system include: Participation in Community Care of North Carolina (CCNC). CCNC is a public-private partnership that provides care management for low-income people enrolled in Medicaid or the Children s Health Insurance Program (CHIP) in North Carolina. The partnership includes 14 regional networks, each of which is itself a partnership of local providers, including hospitals, primary care physicians, county health and social services departments, and other stakeholders. Durham Community Health Network (DCHN) participates in one of the 14 networks. CCNC provides resources, information, and technical support to these networks. In exchange for participating in the networks quality improvement programs, primary care practices receive $2.50 per patient, per month in addition to fee-for-service reimbursement. Networks receive $3 per patient per month. DCHN employs approximately 15 care managers, who are specially trained nurses, social workers, nutritionists, or community health workers. They provide education and information to individual patients and their families and help identify barriers to care, such as inadequate transportation or housing, and monitor patient outcomes. DCHN also implements programs to address targeted chronic diseases and to encourage prevention and health maintenance. For example, DCHN has created an information technology system that sends s to care managers alerting them to important, real-time information such as visits to the emergency department, unfilled prescriptions, and visits to specialists for tests. Between 2006 and 2008, proactive surveillance of health care data for 20,000 Medicaid beneficiaries generated almost 12,000 notices to care managers. Better data and consistent case management have improved outcomes across the state. For example, from 1999 to 2003, the percentage of CCNC patients with asthma who were on maintenance medications increased from 60 percent to 93 percent, and the percentage receiving flu shots increased from 19 percent to 58 percent. Between 2002 and 2006, hospital admission rates for patients with asthma declined by 40 percentage points. 5

6 Partnership with Lincoln Community Health Center. Duke partners with its local FQHC in Durham County the Lincoln Community Health Center, on a number of primary care programs, including: Local Access To Coordinated Healthcare (LATCH), which provides care to the uninsured The Just For Us program, which offers home services to elderly and disabled adults in Durham s public and subsidized housing facilities and group homes who cannot otherwise access care The Lyon Park and Walltown Neighborhood Clinics, which provide a wide range of services to underserved areas of Durham Project Each of these programs was developed in response to local need, sometimes arising directly from community groups and members; others began from analysis of ER visits and the discovery of clusters of patients who were using the ER rather than local primary care offices. Programs are jointly developed between the community, the FQHC, and Duke, with Duke often taking the lead in planning and financial start-up support. Services are not limited to primary care; specialty care is provided without charge via Duke and private physicians for Durham County residents who are uninsured and maintain a health home at Lincoln or one of its satellite clinics. Durham Health Innovations (DHI). DHI is a communitywide initiative co-led by the Durham County Health Department to improve health status. Funding for DHI has come from Duke and from its Clinical and Translational Science Award from the NIH. Through this funding, 10 teams of community members and Duke faculty and staff each received funding to assess the status of specific clinical conditions or risk factors in underserved populations in Durham and to establish targeted interventions and ideas. The research work used surveys, town hall meetings, geospatial mapping of disease prevalence, and use of services to locate target populations at high risk combining regional claims data analysis to identify clusters of high-intensity disease conditions and relied on community input, including interviews and surveys, to understand potential issues and causes. While each team identified customized solutions for the clinical condition or population they were sent to evaluate (i.e., asthma, adolescent health), several consistent success factors for intervention emerged from each team, including: Patient navigation and care coordination Application of information technology (IT) to share critical clinical information Group care Increased use of advanced practice clinicians (APCs) Use of social hubs to influence health Co-location of services Social marketing Enhanced use of metrics and quality improvement methods 6

7 Duke Family Medicine Center. The faculty practice within the Department of Community and Family Medicine at the School of Medicine serves as the Patient-Centered Medical Home for more than 13,500 patients in Durham County. The practice is recognized by the National Committee for Quality Assurance (NCQA) as a level three Patient-Centered Medical Home. It is a test site for care redesign as well as the core teaching site for family medicine residents and for medical physician assistant, nursing, and pharmacy students. Duke Primary Care Clinics (DPC). DPC is a group of 140 providers operating throughout the community and the state of North Carolina. Expanding rapidly, DPC makes strong use of physician assistants, nurse practitioners, and other providers working at the top of their training. DPC serves a diverse beneficiary base including commercial payers and public payers. Duke Primary Care has implemented open access scheduling, which leaves large blocks of primary care providers time unscheduled. Patients, including those in DCHN, are able to call and request same-day appointments, minimizing the use of urgent care clinics and emergency departments for primary care treatment. They are also able to schedule online through Duke s patient portal. DPC operates in coordination with the Departments of Community and Family Medicine, Internal Medicine, and Pediatrics, which oversees the credentialing and appointment processes. Figure 1: Duke Medicine Primary Care Services & Community Interface 1 Duke University Health System Duke University School of Medicine Duke Primary Care Durham Community Health Network (Part of Northern Piedmont Community Care) Community Care North Carolina Lincoln Health Center FQHC Duke University School of Nursing Duke Primary Care Research Consortium Department of Community and Family Medicine Division of Community Health Duke Translational Medicine Institute Duke Center for Community Research Primary Care for the Durham Community Durham Health Innovations Durham County Health Department Commercial Payers Durham County Department of Social Services 7

8 Factor 3: Integrate research programs, funding, and results into the primary care delivery system The Duke Translational Medicine Institute (DTMI) was established in 2006 to coordinate the Duke CTSA programs and to enhance clinical and translational research at Duke. DTMI aims to identify quickly scientific discoveries that improve population health and incorporate them into patient care. Two key areas within DTMI focus on primary care and community engagement: the Duke Center for Community Research and the Primary Care Research Consortium. Duke Center for Community Research (DCCR). DCCR serves as Duke s liaison for research in community settings. The DCCR works with community partners to develop research agendas and strategies to implement research findings into community-based clinical care. The DCCR is jointly governed by Duke and a Community Advisory Board, giving a governance role to community stakeholders. Primary Care Research Consortium (PCRC). Within the Duke Clinical Research Institute (DCRI), PCRC supports clinical trials and studies to test mechanisms to improve health care delivery and health outcomes. The network is made up of clinical practices within the Duke University Health System and unaffiliated clinical and social service providers in Durham County and neighboring communities. The PCRC conducts research to support evidence-based medicine while providing educational and clinical trial participation opportunities to providers. Duke primary care practices are active participants in clinical trials, having participated in more than 70 clinical studies since 1996, including those sponsored through PCRC. Factor 4: Invest in primary care education Duke has actively revamped its educational programs to address the shortage of primary care practitioners and better prepare clinicians to care for a population s health. It offers a wide range of programs through the Schools of Medicine and Nursing to prepare primary care clinicians. The Physician Assistant (PA) program trains approximately 150 students each year. The School of Nursing offers several degrees, including an accelerated bachelor of science in nursing degree, a master of science, a post-master s certificate, a doctorate of nursing practice, and a Ph.D. program. There are more than 60 faculty members teaching more than 700 nursing students. Physicians, nurses, nurse practitioners, and physician assistants are trained not only in how to prevent and treat disease, but also in how to engage patients and manage their care between visits and care settings. For example, in the Family Medicine Residency Program, physicians are trained in team-based health care, chronic disease management, community engagement, leadership, and quality measurement and improvement. In addition, medical, nursing, and physician assistant students attend team-based learning sessions together. Duke is working to expand the number of primary care clinicians. Duke offers a new four-year curriculum in primary care leadership, including scholarships to medical students who pursue primary care through the Primary Care Leadership Track. Courses are integrated where possible with current classes, with differentiation when a stronger primary care focus is needed. The core clinical year, for 8

9 instance, is based in continuity practices, rather than primarily in inpatient settings. Students who sign a letter of intent to pursue a career in primary care receive a scholarship of $10,000 per year. This reverts to a loan if the student enters a non-primary care field. The Nursing School received a $1.3 million federal grant to increase enrollment and graduation rates of nurses in primary care and family nursing programs to address provider shortages. One defining feature of the PCLT is the clerkship year, which replaces traditional block rotations in the inpatient setting with a longitudinal integrated curriculum primarily in an ambulatory setting. Factor 5: Leverage information technology and use the data Duke Medicine was an early innovator in leveraging health information technology. Duke has implemented a Decision Support Repository, clinical registries, and geospatial mapping to help identify appropriate interventions, monitor patients health status, and intervene early in patients experience with disease, and is now investing in a systemwide electronic health record, which will span from community-based primary care to inpatient and tertiary care. Decision Support Repository. When a patient visits any of the three hospitals or 116 outpatient clinics, a host of clinical and administrative data are captured in the DUHS electronic medical record. The data may include diagnoses, procedures, medications, demographics, and financial information. These data are then used to populate Duke s Decision Support Repository (DSR). The DSR is a clinical data warehouse that contains records for more than 3.8 million patients, and is used to support research, operations, and clinical effectiveness, including: Clinical registries: Duke uses clinical registries to track patient care, enabling clinicians to monitor provision and adherence of recommended therapies. These registries have proven invaluable in tracking key metrics (i.e., A1C levels in patients with diabetes), enabling better coordination in delivering care, and improving understanding of the effect of interventions. Care coordination: Data from ER visits and hospitalizations are used in scheduling care manager calls and home visits, so that reasons for avoidable episodes of care are identified and resources brought to bear as needed. An individual ER visit, for instance, might be followed by a phone call from a care manager the next day to ensure follow-up, while a cluster of ER visits or admissions may lead to a finding of missing or poorly coordinated resources. Geospatial mapping: Duke uses a technique known as geospatial mapping, which links transactional and claims data with community resource information to identify geographic clusters of risk factors or disease. Researchers and clinicians can then work with community health agents to target interventions for those communities. For instance, researchers at the School of Medicine used high-resolution geospatial analysis to identify neighborhoods in Durham County with high incidence of breast cancer in young women. They then targeted those neighborhoods for educational and early-detection interventions. HealthView portal: This tool provides a patient the ability to schedule, in real time, a primary care visit at Duke Family Medicine, DPC, or Duke Children s Primary Care. When they arrive at a clinic, patients can register at a self-service kiosk with a bar-coded appointment slip they have printed at home. The HealthView portal also supports patients access to lab results. 9

10 An emerging accountable health system Duke s primary care capability forms a foundation that can serve as the basis for implementing care that is accountable to a larger community. While new payment models to support such a system are still in their infancy in North Carolina, they are beginning to emerge. With its experience in primary care and community health, Duke is well positioned to add provider capacity, strengthen its research, and attract students to a comprehensive primary care system that is deeply engaged with its community in improving health. The five success factors outlined in this case study all contribute to an overall shift in focus away from silos of medical specialties toward a more coordinated system with the health of the population at its center. 10