Kevin T. Rich, MD, FAAFPChief Medical Officer| Family Medicine Residency of Idaho, Boise, IdahoAssociate Professor of Family Medicine | University of Washington SOM

Assistant Clinical Professor | Idaho State UniversityPast President | Idaho Academy of Family Physicians

Chair, Practice Transformation Committee| Idaho Medical Home CollaborativeChair, Regional Healthcare Collaborative | Idaho Healthcare Coalition

Patient Centered Medical Home28th Annual Idaho Conference on Health Care

8th Annual Thomas Geriatric Health Symposium October 2, 2015

PCMH in Idaho – What it is and What it will become

IN AN AVERAGE MONTH:

White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885-892.Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001;344:2021-2025

.

PRIMARY CARE = QUALITY

PRIMARY CARE = LOWER COST

INCREASED GENERALIST CARE = HIGHER QUALITY

INCREASED GENERALIST CARE = LOWER COSTS

INCREASED SPECIALTY CARE = WORSE QUALITY

INCREASED SPECIALTY CARE = HIGHER COST

PATIENT CENTERED MEDICAL HOME

· Place

· Process

PATIENT CENTERED MEDICAL HOME NEIGHBORHOOD

RATIONALE FOR THE BENEFITS OF PRIMARY CARE FOR HEALTH Greater Access to Needed Services

Better Quality of Care

A Greater Focus on Prevention

Early Management of Health Problems

Cumulative Effect of Primary Care to more Appropriate Care

Reducing Unnecessary and Potentially Harmful Specialist Care

Source: Starfield B., Leiyu S., Mackinko J., Contribution of Primary Care to Health Systems and Health, (Milbank Quarterly, Vol. 83., No. 3, 2005) 457-501)

PATIENT CENTERED MEDICAL HOME

· Place· Process

PCMH: WHAT DOES IT LOOK LIKE IN PRACTICE? “Integrated and coordinated care with the patient at the center”

“A continuous relationship with a personal physician/physician team occurs, coordinating care for both wellness and illness.”

Fundamental principles: Improved access to care

Comprehensive care

Whole person orientation

Care management

Continuity of care

Team approach to care

Culture of quality and safety

Integration of health information technology to improve access to care, quality of care and patient safety.

PCMH DEFINITIONS/TERMINOLOGY

Standards NCQA

URAC

TransforMed

Change Concepts McColl Institute

SNMHI/Qualis

PCMH STANDARDS TransforMed Access to Care and

Information

Practice Services

Care Management

Continuity of Care Services

Practice-Based Care Team

Quality and Safety

Health Information Technology

Practice Management

· NCQA Enhance Access and

Continuity

Identify and Manage Patient Populations

Plan and Manage Care

Provide Self-Care Support and Community Resources

Track and Coordinate Care

Measure and Improve Performance

CHANGE CONCEPTS Engaged Leadership

Quality Improvement Strategy

Empanelment (linking each patient with a provider)

Continuous, Team-Based Healing Relationships

Patient-Centered Interactions

Organized, Evidence-Based Care

Enhanced Access

Care Coordination

MS. G Ms. G is a 48 yo single mother of three teenagers who does

domestic work.

She is underinsured and receives her care at a public hospital clinic.

BMI of 37, poorly controlled diabetes, elevated blood pressure and painful osteoarthritis of her knees.

Chronically depressed and has required opioids to control her knee pain. She frequently misses her doctor appointments, and the clinic suspects that she is not taking her medications (including opioids) as prescribed. Her depression seems to be unresponsive to meds, and her symptoms are making it harder for her to work.

Ms. G became increasingly fatigued and dyspneic, and was admitted in CHF.

MS. G’S MEDICAL CARE PER CHANGE CONCEPT

Enhanced Leadership

Leadership preoccupied with financial status*Ensure that the PCMH transformation effort has the time and resources needed to be successful.*Ensure that providers and other care team members have protected time to conduct activities beyond direct patient care that are consistent with the medical home model.

Quality Improvement Strategy

Performance measurement limited to required reports. Occasional QI projects.*Ensure that the PCMH transformation effort has the time and resources needed to be successful.*Ensure that providers and other care team members have protected time to conduct activities beyond direct patient care that are consistent with the medical home model. *Ensure that patients/family, providers, and care team members are involved in quality improvement activities

Empanelment No effort to link patients with primary care teams. Despite poor disease control and missed appointments, practice has never tired to initiate a visit.*Assign all pts’. a panel*Use panel data and registries to proactively contact and track patients

Continuity and Team-Based Care

She sees whoever has an appointment available that day. MD’s have no defined team.*Link patients to a provider and care team that are accountable to the care of pts. Define roles and distribute tasks among care team members

Organized Evidence-Based Care

Care delivered in brief, reactive visits. Her no-shows make it hard to titrate meds. No staff available to provide more intensive follow-up. *Identify high risk groups and ensure they get care needed;*Planned care visits;*Evidence-based POC reminders

Access No evening or weekend appointments make it difficult for her to work and keep appointments.*24/7 access via phone, email, *Open access scheduling

Coordination The clinic was unaware that she went to the ED with symptoms of CHF and was admitted. She was readmitted 3 weeks after discharge having had no outpatient care.*Follow up with patients within a few days of an emergency room visit or hospital discharge.*Communicate test results and care plans*Link pts. with community resources and communicate with referrals

Patient-Centered Interactions No trained self-management support. She often doesn’t understand what the MD’s tell her to do.*Post visit f/u- print or email care visit summaries*Care plans

TRANSFORMATION What is it?

Practice Redesign

Looking at a different way of delivering careo “Integrated and coordinated care with the patient at the center”o “A continuous relationship with a personal physician/physician team

occurs, coordinating care for both wellness and illness.” Fundamental principles:

Improved access to care Comprehensive care Whole person orientation Care management Continuity of care Team approach to care Culture of quality and safety Integration of health information technology to improve access to care,

quality of care and patient safety.

THE PCMH DATA-TO-DATE Excellent ROI

Geisinger Health Systems, Group Health Cooperative, MultiCare, Dean Health System, CCNC, IHC

Quality of Care, Patient Experiences, Care Coordination, and Patient Access all Improve

Decrease ER Utilization 15-50% (Avg. 30%)

Decrease Hospitalization 10-40% (Avg. 19%)

Decrease Cost/Patient $835-$1,750/Year

Increase Patient Satisfaction and Decrease Physician Burnout

THE FUTURE OF THE MEDICAL HOME IN IDAHO

WHAT IS THE SHIP?

The State Healthcare Innovation Plan (SHIP) is a

statewide plan to redesign our healthcare delivery

system, evolving from a volume-driven, fee for service

system to a outcome-based system that achieves the

triple aim of improved health, improved healthcare

and lower costs for all Idahoans.

IDAHO SHIP MODEL ELEMENTS Strong Primary Care System

Patient Centered Medical Homes (PCMH) – Foundational

Medical Neighborhood (Hospitals, Subspecialists, Others)

Regional Cooperatives (RC) Support Local Primary Care Providers and Medical Neighborhood

Statewide Idaho Healthcare Coalition (IHC)

IDAHO SHIP MODEL ELEMENTS Health Information is Linked Electronically by EHR

and HIT

Data Analytics

Payment Systems are Aligned Across Major Payers

Patient Engagement/Accountability

Transforms Public Health to Population Health

Regional Collaborative

Patient Centered Medical Home (PCMH)

Patient Centered Medical Home Neighborhood

Idaho Healthcare Coalition (IHC) / SHIP

IDAHO HEALTHCARE COALITION (IHC) MODEL TESTING GRANT $61M Grant (CMMI)

Notified November 5, 2014 – $40M

Four Years

Achieve Triple Aim: Better Health; Better Healthcare, Lower Costs

Projected Savings $89M/Three Years

ROI (197%) over Five Years

IHC MODEL TESTING GOALS 180 Primary Care Practices (PCMH’s) over Three Years

(900 PCP’s); 1.3M People (80%)

EHR/HIE Integration (PCMH / Neighborhood)

Build Seven Regional Collaboratives

75 Virtual PCMH’s (>550 CHW’s/CHEMS) / Telehealth

Data Analysis – Collecting, Analyzing, Reporting

Align Payment Mechanisms

IDAHO HEALTHCARE COALITION (SHIP) SUMMARY Vehicle and Model for Healthcare Transformation for Idaho

Built on Foundation of Primary Care and the Patient Centered Medical Home (PMCH)

Integrates and Coordinates the PCMH with Secondary Providers, Hospitals, and Other Members of Healthcare Team

Connects Public Health to Population Health Quality Metrics

Integrates Clinical and Claims Data

Aligns Payment Systems with Access and Outcomes

Transforms Health Care in Idaho Triple Aim

INTEGRATION· EMR· PCMH· PCMH

Neighborhood· Hospitals· ACO

SYMPHONY OF CARE

THE IMPORTANCE OF FM/PC AND THE PCMH TO IDAHO’S TRANSFORMING HEALTH CARE SYSTEM The Backbone

First Line of Care

Leverages Relationships, Continuity, Comprehensiveness

Focuses on Health

Integrates and Coordinates

Bridge to Other parts of the Health Care System when Needed

This is the Future of Health Care in Idaho

THE PCMH IN IDAHO TODAY AND TOMORROWTODAY

· Concept – Adolescence

· Implementation – Childhood

· Payment – Infancy

· Potential – Value-Add

TOMORROW

Adulthood

Adulthood

Young Adulthood

Tremendous Value-Add

QUESTIONS