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The Effect of Primary Health The Effect of Primary Health Care Orientation on Chronic Care Orientation on Chronic Illness Care Management Illness Care Management

Julie Schmittdiel, Ph.D.,Julie Schmittdiel, Ph.D.,

Stephen M. Shortell, Ph.D., Stephen M. Shortell, Ph.D.,

Thomas Rundall, Ph.D.Thomas Rundall, Ph.D.

AcademyHealth Annual Research MeetingAcademyHealth Annual Research Meeting

June 7, 2004June 7, 2004(Funded by Robert Wood Johnson Foundation Award (Funded by Robert Wood Johnson Foundation Award

#038690)#038690)

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IntroductionIntroduction Chronic illness places huge burden on U.S. Chronic illness places huge burden on U.S.

health care system: 125 million patients health care system: 125 million patients generate 75% of costsgenerate 75% of costs

Institute of Medicine(2001) reports a Institute of Medicine(2001) reports a “quality chasm” in chronic illness care “quality chasm” in chronic illness care provided to patientsprovided to patients

Improving chronic illness care delivery in Improving chronic illness care delivery in the primary care setting has great the primary care setting has great potential for helping bridge chasm potential for helping bridge chasm (Bodenheimer, Wagner and Grumbach (Bodenheimer, Wagner and Grumbach 2002)2002)

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Introduction, cont.Introduction, cont.

Focus on acute problems and episodic care Focus on acute problems and episodic care makes current primary care system ill-makes current primary care system ill-equipped to deal with chronic illnessequipped to deal with chronic illness

A focus on comprehensive care and overall A focus on comprehensive care and overall patient health (primary patient health (primary health health care) could care) could create an ideal environment for improved create an ideal environment for improved chronic illness carechronic illness care

Lack of empirical work examining whether Lack of empirical work examining whether greater primary health care orientation greater primary health care orientation relates to improved chronic illness care relates to improved chronic illness care processesprocesses

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Research QuestionResearch Question

Does a physician organization’s Does a physician organization’s primary health care orientation primary health care orientation affect its delivery of chronic affect its delivery of chronic illness care?illness care?

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The Chronic Care Model* The Chronic Care Model* (Wagner et al)(Wagner et al)

Community Linkages: mobilize community resources for Community Linkages: mobilize community resources for chronic illness patients chronic illness patients

Health System Organization: leadership commitment to Health System Organization: leadership commitment to chronic illness care and its outcomechronic illness care and its outcome

Patient Self-Management Support: encourage lifestyle Patient Self-Management Support: encourage lifestyle changes and developing of illness management skillschanges and developing of illness management skills

Delivery System Design: offer team-based care and Delivery System Design: offer team-based care and patient follow-uppatient follow-up

Decision Support for Providers: train providers in Decision Support for Providers: train providers in evidence-based guidelines and give access to specialist evidence-based guidelines and give access to specialist expertise expertise

Clinical Information Systems: electronic medical data Clinical Information Systems: electronic medical data systems; use for provider feedback, reminders, and care systems; use for provider feedback, reminders, and care planning planning

*See www.improvingchroniccare.org for more details*See www.improvingchroniccare.org for more details

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Primary Health Care (Starfield Primary Health Care (Starfield 1992)1992)

1.1. First ContactFirst Contact: primary care providers : primary care providers provide window to use of specialistsprovide window to use of specialists

2.2. Continuity:Continuity: primary care provider/patient primary care provider/patient relationship is long-term and consistentrelationship is long-term and consistent

3.3. Comprehensiveness:Comprehensiveness: primary care primary care provides wide range of services across provides wide range of services across settingssettings

4.4. Coordination:Coordination: primary care coordinates primary care coordinates with care from other sourceswith care from other sources

5.5. AccountabilityAccountability : primary care providers : primary care providers feel ultimately responsible for overall feel ultimately responsible for overall patient healthpatient health

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Research HypothesisResearch Hypothesis

Similarities across concepts suggest Similarities across concepts suggest that organizations practicing primary that organizations practicing primary health care may be more committed to health care may be more committed to the Chronic Care Model. the Chronic Care Model.

Research Hypothesis: Physician Research Hypothesis: Physician organizations with a high degree of organizations with a high degree of overall primary health care orientation overall primary health care orientation will have a higher degree of Chronic will have a higher degree of Chronic Care Model implementation.Care Model implementation.

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Data SourceData SourceNational Study of Physician Organizations* (NSPO)National Study of Physician Organizations* (NSPO)

Cross-sectional survey of all U.S. physician Cross-sectional survey of all U.S. physician organizations with 20 or more MDsorganizations with 20 or more MDs

Data collected from Sept. 2000-Sept. 2001Data collected from Sept. 2000-Sept. 2001

Assessed chronic illness care processes, IT, Assessed chronic illness care processes, IT, external incentives, organizational/financial external incentives, organizational/financial characteristicscharacteristics

70% response rate; n=64 treating no chronic 70% response rate; n=64 treating no chronic illness deletedillness deleted

Result of n=1,040 organizations for analysisResult of n=1,040 organizations for analysis*further information and survey instrument available at *further information and survey instrument available at http://nspo.berkeley.eduhttp://nspo.berkeley.edu

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Dependent Variable: Dependent Variable: Chronic Care Model IndexChronic Care Model Index

11-point Chronic Care Model Index 11-point Chronic Care Model Index Mean(SD)Mean(SD)

4.6 (2.9)4.6 (2.9)

Agreements with Comm. Services Agencies Agreements with Comm. Services Agencies 20.2%20.2%

Referrals to Comm. Services Agencies Referrals to Comm. Services Agencies 32.4%32.4%

Assess Self-Management Needs Assess Self-Management Needs 44.8%44.8%

Self-Management Programs Self-Management Programs 56.6%56.6%

Integrate Guidelines into Care Integrate Guidelines into Care 51.4%51.4%

Integrate Specialists into Care Integrate Specialists into Care 62.2%62.2%

Utilize Planned Visits Utilize Planned Visits 56.0%56.0%

Multiple Providers Seen in one Visit Multiple Providers Seen in one Visit 36.3%36.3%

Employ Case Managers Employ Case Managers 34.2%34.2%

Written Feedback to MDs Written Feedback to MDs 36.6%36.6%

Internet Comm. between MDs and PatientsInternet Comm. between MDs and Patients 25.9%25.9%

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Independent Variables: Independent Variables: Primary Health Care OrientationPrimary Health Care Orientation Comprehensiveness:Comprehensiveness: Severe Chronic Illness Treated in Primary CareSevere Chronic Illness Treated in Primary Care (range 0-4) (range 0-4) mean (SD)mean (SD)

.50 (.90).50 (.90)

Health Promotions Index (range 0-8) Health Promotions Index (range 0-8) mean (SD)mean (SD) 2.5 (2.6)2.5 (2.6) Patient Education Index (range 0-4) Patient Education Index (range 0-4) mean (SD)mean (SD) 2.4 (1.5)2.4 (1.5) Coordination:Coordination: Use of Electronic Medical Record Use of Electronic Medical Record (% yes)(% yes) 21.0%21.0% Use of Electronic Standardized Problem List Use of Electronic Standardized Problem List (% yes)(% yes) 17.7%17.7% Accountability: Accountability: Required Outside Reporting Index (range 0-4) Required Outside Reporting Index (range 0-4) mean (SD)mean (SD) 0.8 (1.4)0.8 (1.4) % Patients PO Accepts Risk for Hospital Costs % Patients PO Accepts Risk for Hospital Costs mean (SD)mean (SD) 22.0 22.0

(36.3)(36.3) Continuity:Continuity: Primary Care Physician % Turnover Rate – mean (SD)Primary Care Physician % Turnover Rate – mean (SD) 5.7 (8.4)5.7 (8.4)

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Method of Analysis: Method of Analysis: Multivariate Linear RegressionMultivariate Linear Regression

Chronic Care Model Implementation Index Chronic Care Model Implementation Index = =

ff(Primary Health Care Orientation (Primary Health Care Orientation Variables, Variables,

control variables*)control variables*)

*controlling for organization age, size, number of *controlling for organization age, size, number of clinics, region, ownership, organization type, clinics, region, ownership, organization type, capitalization, county-level HMO penetrationcapitalization, county-level HMO penetration

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Analysis ResultsAnalysis ResultsPrimary Health Care Orientation VariablesPrimary Health Care Orientation Variables BB (S.E) (S.E)Comprehensiveness:Comprehensiveness:Severe Chronic Illness Treated in Primary CareSevere Chronic Illness Treated in Primary Care .21* (.08).21* (.08)Health Promotions Index Health Promotions Index .39***(.0.39***(.0

3)3)Patient Education IndexPatient Education Index .28*** .28***

(.05)(.05)Coordination:Coordination:Use of Electronic Medical RecordUse of Electronic Medical Record .30 (.23).30 (.23)Use of Electronic Standardized Problem List Use of Electronic Standardized Problem List .51* (.23).51* (.23)Accountability:Accountability:Required Outside Reporting Index Required Outside Reporting Index .25** .25**

(.06)(.06)% Patients PO Accepts Risk for Hospital Costs% Patients PO Accepts Risk for Hospital Costs .006*(.00.006*(.00

2)2)Continuity:Continuity:Primary Care Physician % Turnover RatePrimary Care Physician % Turnover Rate -.01 -.01

(.009)(.009)

*** = p<.001; ** = p<.01; * = p<.05

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Summary of ResultsSummary of Results

Strong support for Research Hypothesis Strong support for Research Hypothesis Six of eight primary health care orientation Six of eight primary health care orientation

variables significantly related to index of variables significantly related to index of Chronic Care Model implementationChronic Care Model implementation

Low levels of primary health care Low levels of primary health care orientation in U.S. physician orientation in U.S. physician organizationsorganizations

Limited use of Chronic Care Model Limited use of Chronic Care Model

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Health Policy ImplicationsHealth Policy Implications

Empirical justification for improving Empirical justification for improving chronic illness care within a primary chronic illness care within a primary health care settinghealth care setting

Increasing primary health care Increasing primary health care orientation in physician organizations orientation in physician organizations may improve chronic illness care may improve chronic illness care processesprocesses

By facilitating changes in the primary By facilitating changes in the primary care system, stakeholders could benefit care system, stakeholders could benefit people with chronic illnesspeople with chronic illness

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ConclusionConclusion

Chronic illness places a great burden Chronic illness places a great burden on health care systemon health care system

This and other research demonstrates This and other research demonstrates much room to improve quality of much room to improve quality of chronic illness carechronic illness care

Creating a health care system with a Creating a health care system with a greater primary health care orientation greater primary health care orientation may help bridge quality chasm in may help bridge quality chasm in chronic illness carechronic illness care