The Medical Neighborhood

A Primary Care ViewpointA Primary Care Viewpoint

R. Scott Hammond, M.D., FAAFPR. Scott Hammond, M.D., FAAFPAssociate Clinical Professor, University of Associate Clinical Professor, University of

Colorado School of MedicineColorado School of Medicine

shammond@evcohs.comshammond@evcohs.com

Problems with care coordinationProblems with care coordination

Coordination Research Source

PCP and Specialist 49% of referrals to specialist had no information. Specialist sent info 55% of time.

Forrest. Arch Ped Adol Med. 2000

25% of specialist reports received > 1 month after visit

Gandhi. J Gen Int Med. 2000

34.8 % of specialists receive proper notification and information "always" or "most of the time.

Arch Intern Med. 2011;171(1):56 - 65

62.2 % of PCPs reported getting consultation reports "always" or "most of the time.”

Arch Intern Med. 2011;171(1):56 - 65

52% specialists receive necessary information “always” or “regularly”

2011 Colorado SOC Survey - Kupersmit Research 2011

38% PCPs included in care/support in role “always” or “regularly”

2011 Colorado SOC Survey - Kupersmit Research 2011

PCMH without a neighborhoodPCMH without a neighborhood

Strengthening Medical Home ModelsStrengthening Medical Home Models

Barrier to Success of Barrier to Success of Medical HomeMedical Home

•• Resistance to CollaborationResistance to Collaboration•• Few incentives for hospitals and Few incentives for hospitals and

specialists to collaborate with PCPspecialists to collaborate with PCP•• SingleSingle--based data systems based data systems

insufficientinsufficient

•• Lack of Uncertainty of supportLack of Uncertainty of support•• Patient acceptability, fear of gatePatient acceptability, fear of gate--

keepingkeeping•• Specialist acceptability, income Specialist acceptability, income

threatenedthreatened

•• Difficulty controlling costsDifficulty controlling costs•• Outside influences on costsOutside influences on costs•• Savings in subpopulation offset by Savings in subpopulation offset by

increased spending elsewhereincreased spending elsewhere

Approaches to Overcome Approaches to Overcome BarriersBarriers

•• Share information among Share information among providersproviders•• Require MH to specify networks for Require MH to specify networks for

performance measures and information performance measures and information sharingsharing

•• Require providers to meet connectivity Require providers to meet connectivity standardsstandards

•• Establish performance Establish performance measurements and rewardsmeasurements and rewards•• Transparency across continuum of careTransparency across continuum of care•• Reward collaborationReward collaboration

•• Institute broad accountability for Institute broad accountability for populationpopulation--based savingsbased savings•• Foster integrated delivery systems that Foster integrated delivery systems that

share savings from Triple Aimshare savings from Triple AimFisher,E. Building a Medical Neighborhood for a Medical Home. N Engl J Med 2009;359:1202- 5

Learning objectivesLearning objectives

Working TogetherWorking Together

Working TogetherWorking Together What CAN a PCMH do?What CAN a PCMH do?

•• Care coordinator job description and protocol Care coordinator job description and protocol consistent with available resources.consistent with available resources.•• Patient Navigator/Disease Management/Health CoachPatient Navigator/Disease Management/Health Coach

•• External care coordinationExternal care coordination•• Hospital and skilled nursing facilitiesHospital and skilled nursing facilities•• SpecialistsSpecialists

•• Internal care coordinationInternal care coordination•• HighHigh--acuity patientsacuity patients

•• PostPost--hospitalhospital•• MultiMulti--morbid diseasesmorbid diseases•• Frequent ED utilizationFrequent ED utilization

Building a NeighborhoodBuilding a Neighborhood

Phase 1: Planning – Vision, Compact

Phase 2: Implementation – 5As

Phase 3: Evaluation

Phase 4: Sustainability and Continuous Improvement

Building a NeighborhoodBuilding a Neighborhood

Phase 1: Planning – where to start

Complain Have a meetingSchedule more meetingsHave a clear expectation for deliverablesDo the hard work – focus on solutions not

problemsPatience and persistence

Phase 2 Phase 2 –– the 5 Athe 5 Ass

ADVISE: The Implementation Message

-- You as PCPs survive and thrive!You as PCPs survive and thrive!

-- Benefits to a PCMHBenefits to a PCMH--NN•• PatientsPatients

•• Activated, prepared, engagedActivated, prepared, engaged•• Specialty Care PhysiciansSpecialty Care Physicians

•• Maintain autonomy, known for quality care, more exclusive Maintain autonomy, known for quality care, more exclusive patient volume from PCPpatient volume from PCP

•• Practice of MedicinePractice of Medicine•• Reclaim the joy of medicine, camaraderie, why you went into Reclaim the joy of medicine, camaraderie, why you went into

medicine medicine •• Health CareHealth Care

•• Solvency, sustainabilitySolvency, sustainability——jump start, pioneeringjump start, pioneering——itit’’s the way s the way of the future! of the future!

ASSISTASSIST: : Primary Care Primary Care -- Specialty Care Compact Specialty Care Compact

•• Purpose and PrinciplesPurpose and Principles

•• DefinitionsDefinitions

•• Types of Care Transition Types of Care Transition

•• Service AgreementService Agreement•• Transition of CareTransition of Care•• AccessAccess•• Collaborative Care ManagementCollaborative Care Management•• Patient CommunicationPatient Communication

•• Transition of Care Records (PCP and Transition of Care Records (PCP and Specialist)Specialist)

Building a NeighborhoodBuilding a Neighborhood

Phase 3: Evaluation and Accountability

Score Cards20 measuresAlways or almost always (5); Usually (2.5); Occasionally (0); Rarely (-5); NA8 Must Haves (≥ 2.5)

Transition of Care record auditsPatient surveys

Extending the NeighborhoodExtending the Neighborhood

Phase 4: Sustainability and Spread

Physician-to-physician communicationPhysician ChampionsMandatory emails

Patient educationPamphlet – Welcome to the NeighborhoodWallet cards

Engage

ASSESS: Measurement

Evaluation & MeasurementEvaluation & MeasurementASSESS: Measurement

ASSESS: Measurement

ASSESS: Measurement

Orthopedic 1

Orthopedic 2

Oncology

Dermatology

Cardiology

Surgery 1

Neurology

Orthopedic 3

Ophthalmology

Urology

Surgery 2

GastroenterologyMental Health

OBGYN

Nephrology

WMC Medical Neighborhood WMC Medical Neighborhood •• AllergyAllergy--Immunology Immunology •• CardiologyCardiology•• DermatologyDermatology•• Gastroenterology Gastroenterology •• HematologyHematology--OncologyOncology•• Mental Health Mental Health •• Nephrology Nephrology •• NeurologyNeurology•• OBOB--GYN GYN •• Ophthalmology Ophthalmology •• RheumatologyRheumatology•• Surgery Surgery

•• GeneralGeneral•• Orthopedics (3)Orthopedics (3)•• Spine (2)Spine (2)•• Plastics and HandPlastics and Hand

•• UrologyUrology

50+ Physicians19 Specialty offices

1 Hospital

What did we learn about What did we learn about neighbors?neighbors?

-- Not aware of PCMH or Medical Neighborhood conceptNot aware of PCMH or Medical Neighborhood concept

-- Most willing to participate and believe they are or can fulfillMost willing to participate and believe they are or can fulfill most most expectationsexpectations

•• ““A slam dunkA slam dunk”” , , ““Ideal in principleIdeal in principle””

-- Interpretation of the Interpretation of the CompactCompact not straight forward not straight forward

-- Unclear about definitions of transitions/management relationshiUnclear about definitions of transitions/management relationships ps and patientand patient--centered carecentered care

-- Wide variety of practice infrastructure, capacities, effort andWide variety of practice infrastructure, capacities, effort and barriers barriers to changeto change

•• Staffing, technology, teamworkStaffing, technology, teamwork•• Systems improvement (QI) not on radarSystems improvement (QI) not on radar•• OverwhelmedOverwhelmed•• Progress subject to inertiaProgress subject to inertia

-- Specialists cater to many differing PCP requestsSpecialists cater to many differing PCP requests

-- Transition of Care Record and QI Transition of Care Record and QI are main points of conversationare main points of conversation

R. Scott Hammond, M.D., FAAFPR. Scott Hammond, M.D., FAAFPAssociate Clinical Professor, University of Colorado School of MAssociate Clinical Professor, University of Colorado School of Medicineedicine

shammond@evcohs.comshammond@evcohs.com

Change for the better requires that you shift from assuming excellence to pursuing

excellence.

Tracy Hofeditz, M.D.

CO PCMH Pilot practice