The John D. Stoeckle Center for Primary Care Innovation | 50 Staniford Street, 9th Floor | Boston, MA | 02114

ANNUAL REPORT OCTOBER 2011 – SEPTEMBER 2012

The John D. Stoeckle Center for Primary Care Innovation is devoted to revitalizing and redesigning the delivery of primary care in order to:

• Provide the highest level of clinical excellence

• Provide an extraordinary experience of care for patients and their families

• Create an exciting and fulfilling professional life for current and future primary care

practitioners.

As a reliable and trustworthy source of knowledge and leadership, we will partner with people across the country to improve primary care through collaborative work in research, innovation, education, and policy reform.

TABLE OF CONTENTS

Welcome 03

Education 04

Innovation 9

Research 12

Staff Notes 13

“That Mass General, one of the top academic medical centers in the world, has a center dedicated to primary care underscores its powerful commitment to the critical role of primary care in the redesign and practice of overall care. I am proud to support the Stoeckle Center’s inspiring, innovative, and practical efforts to shape the future of primary care.”

– David Barlow Board Member, Stoeckle Center

Front cover photos, clockwise from top left: Sarah Wakeman, MD, Chief Resident, MGH; Harris Berman, MD, Dean, Tufts University School of Medicine; Nahed Chaoui, Office Manger, Family Medicine North; Ben Crocker, MD, Ambulatory Practice of the Future, MGH

M I S S ION

ADVISORY BOARD

JOHN GOODSON, MD -EXECUTIVE SECRETARY

DAVID S. BARLOW

MICHAEL J. BARRY, MD

GEOFFREY M. BURNS, MD

K AREN J. CARLSON, MD

BARBARA CHASE, MSN, APRN, BC

JOHN PATRICK T. CO, MD, MPH

MARJORIE A. CURRAN, MD

PETER T. GREENSPAN, MD

BRITAIN W. NICHOLSON, MD

ELIZABETH A. RIDER, MSW, MD

LAURA E. RILEY, MD

ERIC C. SCHNEIDER, MD

DAVID Y. TING, MD

ERIC M. WEIL, MD

DIANNE S. WEINFELD

CHARLES H. WEISS, MD

Dear Friends ~

Primary care is all about excellent teamwork. In that vein, 2012 has been a year of strengthening partnerships for the Stoeckle Center. We have worked closely with the leadership of the General Medicine Division at MGH and the MGH Primary Care Administration to integrate our mission with the goals and needs of MGH primary care practices and clinicians. We also partnered with the Partners HealthCare Sys-tem (PHS) Partners in Care team to help primary care practices across PHS become medical homes for our patients and their families. In addition, we developed the first multi-disciplinary leadership academy for primary care practice leaders to better equip them to lead in the new world of health care reform.

Mass General and the PHS Partners in Care patient-centered medical home initiative aims to transform our entire system of primary care practices to a team-based model, driven by quality improvement and supported by information technology. We are supporting our vibrant and healthy practices to empower their clinical teams to deliver coordinated, comprehensive care to all of our patients. Our collective goal is to create a better state of health for all the communities and people we serve. Several Stoeckle Center staff have received extensive training in Lean process improvement to en-hance the support we provide to our practices.

Our Shared Decision Making Program provides patients with accurate information about healthcare options and outcomes, tailors medical treatments to patients’ goals and concerns, and supports providers and patients with tools and health information technology to help them to make better decisions together. The Crimson Care Col-laborative (CCC), the student-faculty collaborative practices designed to give students early exposure to primary care, has been implemented in five practices and has expanded to include health professional students from nursing and other disciplines. CCC has engaged over half of the Harvard Medical School students and has pub-lished academic papers and given presentations at several national meetings. And, the Foster Family Fund allows us to support an annual scholars program for Harvard Medical School students interested in health advocacy and media.

Our mission to redesign and revitalize primary care remains at the forefront of our work. We are honored and privileged to work with the best primary care clinicians and staff in the country. We are inspired every day by their efforts to deliver the highest quality, pa-tient and family-centered care in the world. Indeed, they exemplify our favorite Chinese proverb: “Those who say it cannot be done should not interrupt the person doing it.”

Your primary care is our primary concern,

W E L C OM E

Susan Edgman-Levitan, PA Michael J. Barry, MD Executive Director Medical Director

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AMBULATORY MORTALITY AND MORBIDITY CONFERENCEIn 2010, a new type of Mortality & Morbidity (M & M) Conference was initiated in the General Medicine Division. In cooperation with CRICO-RMF and the Mass General Primary Care Administration, the Stoeckle Center developed and facilitated the initial series of “Ambulatory” M & M conferences—the first to highlight the impor-tant challenges in patient safety in the outpatient setting. Confer-ences are open to generalists in both the inpatient and outpatient arena, as well as all other members of the care team.Unlike traditional M & M conferences, where the objective is to discuss disease states, the Ambulatory M & Ms dissect cases where patient care or outcome was negatively impacted by fail-ures of process, communication, or operations. The Stoeckle Center continues to support these conferences, which are now part of the Ambulatory Risk Management and Patient Safety Program, led by Elizabeth Allen, RN, and Blair Fos-burgh, MD. Stoeckle Center leaders Bill Kormos, MD, and Susan Edgman-Levitan serve on the steering committee. These confer-ences are multidisciplinary and will help us prevent the types of system-related hazards that are often encountered during routine care.

• January 27, 2012: “Wafarin: It Ain’t Only Rats that Need to Worry.” William Kormos, MD, Director of Education, Stoeckle Center

• May 25, 2012: “No News is Not Good News.” Elizabeth M. Allen, RN, MSN, Quality and Safety Specialist. Discussant: Valerie E. Stone, MD, MPH, Director, Primary Care Residency Program; Associate Chief, General Medicine Division

CABOT PRIMARY CARE LECTURE SERIES The Cabot Lectures have been offered at Harvard Medical School (HMS) for several decades, providing a forum for the primary care community to come together to discuss topics including the patient-doctor relationship, community health, ethics, medical anthropology, and global health. The Stoeckle Center and the HMS Center for Primary Care offer the lecture three to four times per year. Invited speakers include national experts, as well as local champions of primary care from the Harvard community.

• November 3, 2011: “Writing for Patients and Consumer Health Publications.” Celeste Robb-Nicholson, MD, MPH; Editor, Harvard Women’s Health Watch; and Harvey B. Simon, MD; Editor, Harvard Men’s Health Watch

• January 24, 2012: “Community Health Workers: A Step in The Right Direction Toward Value-based Health Care.” Heidi Behforouz, MD, Medical & Executive Director, Prevention and Access to Care and Treatment (PACT) Project, Brigham and Women’s Hospital

S T OE C K L E C E N T E R E V E N T S*Speakers/presenters are from Mass General unless otherwise noted.

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Bill Kormos, Stoeckle Center Education Director, kicks off a quarterly Partners in Care Primary Care Knowledge Sharing Dinner, co-hosted by the Stoeckle Center and Partners Community Healthcare Inc., which brings together primary care staff from across the Partners system.

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• April 26, 2012: “Behavioral Economics and Health.” Kevin Volpp, MD, PhD; Director, Leonard Davis Institute Center for Health Incentives & Behavioral Economics, University of Pennsylvania

• May 17, 2012: “Don’t Kill Granny: Competencies in Geriatric Medicine.” Rosanne Leipzig, MD, PhD; Vice Chair, Education, Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine

LITERATURE & MEDICINE: HUMANITIES AT THE HEART OF HEALTH CAREThe Stoeckle Center, with support from the Massachusetts Foundation for the Humanities, hosts a monthly reading and discussion group open to all staff of the MGH Primary Care Community. In these sessions, group members read works of fiction, poetry, memoirs and nonfiction selected to encourage participants to explore the intricate nature of providers’ relationships with patients and each other. Suzanne Koven, MD, MFA, a Mass Gen-eral primary care physician and Boston Globe columnist and essayist, leads the group in discussions focused on issues raised by the readings that are central to the human face of healthcare.

KNOWLEDGE SHARING DINNERS The Stoeckle Center is responsible for planning and managing the Partners in Care Primary Care Knowledge Sharing

Dinner series for all PHS primary care practice staff. Bill Kormos, MD, chairs the planning committee and facilitates the din-ner discussions. Kerry McBride manages preparations and onsite logistics.

These dinners are open to all 367 primary care practices across the system, and typically attract 100-250 people. 91% of at-tendees in the 2012 series said they would make a change in their practice based on the content and group discussions.

• January 18, 2012: “The Group Health PCMH Story: A Report from the Partners’ Site Visit Team.” Frank Harte, MD, North Shore Medical Center, Well Life Medical; Patrick McSweeney, MD, Medical Director, Tri County Medical Associates; Lisa Whittemore, MPH, MSW, Executive Director, Brigham and Women’s Physicians Organization

• March 7, 2012: “High-level Overview of Practice Organization and Flow Management.” Dr. Henry Otero, Virginia Mason Institute; Zara Doyle, MA, Gloria Fandrey, RN, & Nicholas Mascoli, MD, Newton-Wellesley Internists; Nicole Bloor, MD, & Kimberley Hayes-Carvotta, Nicole Bloor, MD PC.

• June 21st, 2012: “Sustaining Energy for Transformation.” Regina Neal, MS, MPH, Senior Consultant, Qualis Health; Jonathan Sugarman, MD, MPH, President and CEO, Qualis Health.

SCHWARTZ CENTER ROUNDSThe Stoeckle Center hosts monthly Schwartz Center Rounds—unique, multi-disciplinary sessions in which hospital staff explore the emotional side of caregiving. A national program with sites across the country, these Rounds are partially funded by the Kenneth B. Schwartz Center. Kathryn Treadway, MD, Leigh Simmons, MD, and Barbara Moscowitz, MSW, LICSW, lead and facilitate discussion. For more information about Schwartz Center Rounds, visit www.theschwartzcenter.org.

• October 19, 2011: “Navigating Blurred Boundaries: Caring for Colleagues.” David Judge, MD; Benjamin Crocker, MD; Theresa Egan, Medical Assistant; Mary Ann Marshall, RN; MGH Ambulatory Practice of the Future

• November 30, 2011: “Can’t Wait to Meet My New Doctor: The Joys and Struggles of Resident Primary Care Practice.” Meghan Shea, MD, Internal Medicine Associates; Susan Mathai, MD, Bulfinch Medical Group

• December 14, 2011: “Informed Dissent: When Reasonable People Refuse.” Marcy Bergeron, ANP; Abigail Zavod, MD, MPH; Paul S. Cusick, MD; Bulfinch Medical Group

• January 18, 2012: “Clouded Vision, Fuzzy Decisions: Helping People Get The Care They Need.” Marcia Zucker, MD, Women’s Health Associates; Mark

Panelists prepare to make their remarks at a Partners in Care Knowledge Sharing Dinner titled, “The Group Health PCMH Story: A Report from the Partners’ Site Visit Team.” From left: Lisa Whittemore, MPH, MSW, Executive Director, Brigham and Women’s Physicians Organization; Frank Harte, MD, North Shore Medical Center, Well Life Medical; Patrick McSweeney, MD, Medical Director, Tri County Medical Associates; and Mike Esters, PCMH Leader, Partners in Care.

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Murakami, MD, Internal Medicine Associates; Maureen Veduccio, RN, Care Management Program; Melissa Vespa, RN, Care Management Program; Lauren Buhl, Student, Harvard Medical School

• February 15, 2012: “Too Much of a Good Thing?: Patient-Doctor Communication in the Digital Age.” Erika Riley, MD, MGH Beacon Hill; Helen Lichtwart, RN, MGH Beacon Hill; Richard Perrotti, Senior Administrative Manager, MGH Beacon Hill; Jonathan Liu Worth, MD, Department of Psychiatry

• March 21, 2012: “Working Within ‘Bonds of Obligation’: A Son’s Promise, a Doctor’s Oath.” Ardeshir Hashmi, MD; Lisa Mortimer, MSW; and Spencer Wilking, MD, MGH Senior Health

• April 25, 2012: “The Last Resort: Ultimatums and the Primary Care Therapeutic Relationship.” Deborah Wood, RN; Erin Smith, LICSW; Stephen Southard, MD; and Leigh Simmons, MD, of MGH Internal Medicine Associates

• May 16, 2012: “Doc, I Don’t Like What You Wrote in My Record!” John Foster, MD, MPH, CMO, North End Waterfront Health; Vincenzo Scibelli, LICSW, Director of Behavioral Health Services, North End Waterfront Health; Paula Moran, MGH Privacy and Security Manager

• June 20, 2012: “The ‘Soft Stuff’ is the Hard Stuff: The End of Life Journey with a Primary Care Patient.” Barbara Kane, MD, Bulfinch Medical Group; Julia Shea, RN, Care Management Program, Bulfinch Medical Group

• September 19, 2012: “Of Patients and Pink Papers: The Challenges of Filing a Section 12.” Alan Moulaison, MGH Police and Security; Andy Gottlieb, NP, Occupational Health; Lisa Sibert Carr, MD, MGH Chelsea HealthCare Center; Skip Atkins, MD, MGH Chelsea HealthCare Center

STOECKLE CENTER SEMINARSStoeckle Center Seminars are made possible thanks to the con-tinued and generous support of Phyllis and Robert Green.These morning seminars are offered monthly and are open to physicians, nurses, nurse practitioners, administrators, and medi-cine/pediatric residents. Invited speakers are frequently experts with national reputations, and the conference has allowed recog-nition of MGH “best practices” within our primary care community. The seminars are attended by an average of 40-50 participants, and evaluations have demonstrated a very positive response.

• October 28, 2011: “Accept, Deny, or Ignore: Primary Care in the Age of Social Media.” Bradley Crotty, MD, Chief Medical Resident, Beth Israel Deaconess Medical Center

• November 18, 2011: “Wellness and Prevention: The Work of Primary Care Now Valued.” John Goodson, MD, Internal Medicine Associates, and Executive Secretary, Stoeckle Center Advisory Committee

• December 16, 2011: “Bringing Health Information to Life.” David Blumenthal, MD, MPP; Samuel O. Thier Professor of Medicine and Professor of Health Care Policy, Harvard Medical School

• April 27, 2012: “Incentives for Healthy Behavior.” Kevin Volpp, MD, PhD; Director of the Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania

• May 18, 2012: “Become A Quicker, Better Doctor for Older Adults.” Rosanne M. Leipzig, MD, PhD; Vice Chair, Education, Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine

• June 22, 2012: “Making an Impact on Depression: Bringing a Collaborative Approach to Depression into Primary Care.” Trina Chang, MD, MPH, Assistant Psychiatrist, MGH Department of Psychiatry; Anne Huppert, MPH, Project Manager, Stoeckle Center; Benjamin Crocker, MD, MGH Ambulatory Practice of the Future; and a patient

E D U C AT I O N

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Blair Fosburgh, MD, Medical Director ARMS (Ambulatory Risk Management and Safety) facilitates the discussion at an Ambulatory Mortality and Morbidity Conference, which is supported by the Stoeckle Center.

A participant peruses materials before a Stoeckle Center program begins.

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“I feel very privileged to have been part of the Foster Scholars Program. It offered me the opportunity to have meaningful interactions with leaders in primary care and to get a better sense of the evolution of their careers, particularly with respect to their pursuit of social justice in medicine.”

– Zoë GottliebFoster Scholar Program Participant

THE FOSTER SCHOLARS PROGRAM LAUNCHESThe Foster Scholars Program at the Stoeckle Center, funded by the Foster Family Fund, supports primary care-oriented medical students with interests in health advocacy, the media, or health policy. During the summer program, Foster Scholars met luminar-ies in these fields and developed their skills to become effective advocates and leaders for primary care professional policy and related issues. The scholars and their projects are:

• Zoë Gottleib: Exploring the Relationship Between Developmental Assets and Food Insecurity in Adolescents from a Low-income Community (mentor: Elizabeth Goodman, MD)

• Aaron Schwartz: Identifying Low-Value Medical Care and Its Determinants (mentor: Michael Chernew, PhD)

• Min Wu: The Effects of Direct-to-Consumer Advertising on Prescription Drug Sales: a Comparative International Analysis (mentors: John D. Seeger, PharmD, DrPh & Jerry Avorn, MD)

2012 speakers for the program featured:• Andrew Morris-Singer, MD, internist: founder and president,

Primary Care Progress

• John Goodson, MD, internist: advocacy for primary care and primary care reform

• Donita Boddie, director of Massachusetts General Hospital Public Affairs: media training

• Mallika Marshall, MD, medicine-pediatrics physician: former HealthWatch reporter for WBZ 4 News on WBZ-TV

• Jon Kingsdale, former director of the Commonwealth Connector: lessons from Mass. Health Exchange experience

• Harris Berman, MD, Dean of Tufts Medical School, former CEO Tufts Health Plan: Mass Health Reform

• David Blumenthal, MD, former National Coordinator for Health Information Technology: health policy in action

• David Bor, MD, Chief of Medicine, Cambridge Health Alliance & Danny McCormack, MD, internist, advocate, and blogger: advocacy at the national level

• Monica DeMasi, MD, Family Medicine Physician: practical advocacy in a community health center

• Eric Fleegler, MD, pediatric emergency medicine: founder of the Online Advocate

• Jessica Gaeta, MD, internist and housing advocate: Boston HealthCare for the Homeless

Foster Scholars and other HMS students meet with David Blumenthal, MD (far left), President of The Commonwealth Fund, to discuss health policy.

CRIMSON CARE COLLABORATIVE CONTINUES TO GROW Our student-faculty collaborative practices help improve access to primary care services while inspiring health professional students to pursue careers in primary care. Medical students, along with nurse practitioner students and undergraduates, design and participate in all aspects of running the practice including clinical care, administration, social services, lab services, patient educa-tion, quality improvement, and research. We now have three sites at MGH: the flagship site at the Internal Medicine Associates, an MGH Chelsea Healthcare center site and a new pediatrics site at MGH Revere Healthcare Center. In addition, the Beth Israel Deaconess Medical Center and Cambridge Health Alliance have both opened a Crimson Care Collaborative (CCC).

The CCC program has proved to be extremely popular—457 students have volunteered to date, and the number of nurse practitioner students through our new partnership with the MGH Institute for Health Professions is growing. We are focusing on interprofessional education, since training in team-based care has been shown to increase student interest in primary care, while improving care for patients. With help from the Harvard Center for Primary Care and the Yawkey Foundation, we presented our work in 2012 in Boston, Maine, California, and Pennsylvania. In addition, we published an article on CCC in Academic Medicine and were featured in the American Academy of Pediatrics Medical Student Newsletter.

R E C RU I T I NG S T U DE N T S I N T O PR I M A R Y C A R E

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Harvard Medical School students/Crimson Care Collaborative volunteers present their work at a conference.

Patient “JL” was a 60-year-old man who had never had a primary care physician. A life-long resident of Chelsea, he worked odd industrial jobs and spent his nights at a boarding house, reading library books and trying to pass the time. His landlord was his main support and they would often spend hours on the back porch, smoking cigarettes and talking. He presented to Chelsea Urgent Care late in the summer with a cough that wouldn’t resolve. His work-up revealed chronic obstructive pulmonary disease and some suspicious looking lesions in his lung. He was referred to the Crimson Care Clinic at MGH Chelsea. JL was nervous at his first visit, not used to so much attention — he was greeted by a team of medical students who assessed his social service needs and arranged for follow-up with specialists and important laboratory tests. He returned for several visits, toting his many inhalers in a plastic bag, finally able to show the students his proper inhalation technique. He decided to stop smoking, inspired in part by working with the

students on his motivation and stages of change. He told us several times that he was inspired to take better care of his health because so many people were invested in him.Months later, JL became sick again and was hospitalized at MGH with severe pneumonia. He was transferred to the intensive care unit and received maximal medical therapy. When it looked like he wasn’t going to survive, staff in the ICU contacted the Crimson Care team because they were having trouble reaching JL’s family, and wanted to alert the family to his worsening status. Unfortunately, the phone numbers for emergency contacts listed in the computer system were incorrect. However, after a thorough search through the medical records, the ICU team was able to make contact with JL’s landlord and his family because of the meticulous documentation in the first-year medical student’s initial Crimson Care social services intake note. Although JL ultimately passed away, it was through team work and collaboration that we were able to attend to JL’s needs, even at the end of his life.

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CRIMSON CARE IN CHELSEA DELIVERS EXEMPLARY HEALING CARE TO FIRST-TIME PATIENT

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PARTNERS IMPROVES PRIMARY CARE THROUGH “PARTNERS IN CARE”

STOECKLE CENTER COLLABORATES WITH PARTNERS IN CAREPrimary care practices in the Partners network are engaged in practice redesign, with the end goal of transformation to a “Medi-cal Home” model of care. This new model of primary care will improve quality of care, quality of work-life, and the patient experi-ence of care. It is a challenging process, both logistically and culturally; fortunately, lots of support is available. The Stoeckle Center is collaborating with the Partners in Care team to help practices navigate this transition. Partners Healthcare and MGH are adopting the models, ap-proaches, and health management tools that will keep our pa-tients healthy through coordinated care, early preventive interven-tions, and chronic disease management. Patients will have better experiences and support to manage their health problems and will avoid unnecessary Emergency Department (ED) visits through expanded access to their care teams. In addition, physicians and staff will experience increased job satisfaction, as they collaborate and utilize all of their clinical and creative skills.

PARTNERS IN CARE LEADS PRACTICE REDESIGNPartners HealthCare has identified the PCMH model as a criti-cal initiative to improve patient care. To support these redesign efforts, in 2012, Partners HealthCare began a relationship with the Virginia Mason (VM) Institute at the Virginia Mason Medical Center, a Seattle-based organization that is nationally recognized for developing a proven team-based care model. Allie Siegel, Charlotte Ward, and Annie Huppert, of the Stoeckle Center, are part of the Partners in Care team, and were trained as process improvement coaches in the tools and methods used by VM to facilitate practice transformation. Allie is helping to lead the Practice Redesign Workshops, which are designed to teach care teams to implement Lean concepts

in their practices. The workshops help physicians build strong practice teams, and teach those teams to identify and eliminate waste and inefficiencies, to deliver both the highest quality and the safest patient care. Charlotte Ward is supporting data management for the care team, and Annie, in her new role as Administrative Director of Women’s Health, is working with practices in care redesign.

LEAN COLLABORATIVE ENHANCES TRANSITION PROGRESS The Stoeckle Center manages the Partners in Care Medical Home Lean Collaborative, a formal follow-up program to the Part-ners in Care Redesign Workshops for physicians and members of their team to continue to improve practice processes by develop-ing and executing an in-depth process improvement project. The course is led by process improvement experts Mary Cramer, MBA, CPHQ, MGH, Process Improvement Program Director and Director, Ambulatory Management and Performance Consulting Team and Dorothy Goulart, MS, RN, BWH, Director for Perfor-mance Improvement.

NCQA COLLABORATIVE ACCELERATES PRACTICE READINESSSusan Edgman-Levitan and Allie Siegel lead the Partners in Care NCQA Collaborative, an interdisciplinary group of six practices from Mass General, Brigham and Women’s Hospital, and North Shore Physicians Group seeking NCQA Patient Centered Medical Home Level 3 recognition in 2013. The goal of the collaborative is to identify where Partners HealthCare can provide meaningful support for practices seeking NCQA recognition, and develop a project plan with critical path items, a cost model for the NCQA recognition process, and operational tools and resources that can facilitate the recognition process for other practices in the Network.

“Thanks again for the outstanding work that you and the Stoeckle Center do! You consistently create interactive, vibrant forums for the sharing and adoption of new ideas and innovations. We all appreciate your efforts!”

– Kathleen MillerKnowledge Sharing Dinner attendee

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John D. Goodson, MD Executive Secretary, Stoeckle Center Advisory Board The 2010 Affordable Care Act (ACA) initiated health care reforms that will both expand access for the uninsured and underinsured and improve disease prevention and health promotion for all patients. Medicare Annual Wellness Visits (AWVs) provide pay-ment for clinicians to work with patients in health promotion and wellness planning. US Preventive Services Task Force-approved screening tests and select vaccinations and immunizations are fully covered for all patients without copayments or deductibles. The AWVs have been available to Medicare patients since 2011. Beginning in 2013, Medicare’s content and documentation expectations increase to include a more detailed assessment of each patient’s ability to sustain basic activities of daily living (ADLs), such as dressing, bathing, safe ambulation, and “instru-mental” ADLs, such as shopping, laundry, and housekeeping. The changes were enacted to encourage physicians to develop an understanding of all factors that might have health implications, such are risks for falling or loss of personal independence. Good primary care has always meant that the clinicians and their col-laborating team members know about the day-to-day lives of their patients—the successes, the challenges, and the risks they face. The new Medicare visits provide payment for these important services. The most significant and meaningful new expectation for the AWV is the completion of a Health Risk Assessment (HRA) question-naire prior to the office visit. The questionnaire can be mailed and completed prior to arrival or completed in the waiting area. The HRA questionnaire is the starting point for a face-to-face discus-sion between patient and doctor. At the AWV, each individual’s capacity with ADLs and IADLs are reviewed, as well as needed screening tests and vaccinations. For example, HRA responses may open a discussion of who might help with house work if this is beyond the patient’s physical capacities. The information from the AWV becomes part of the clinical documentation by the physician and is retained for reference at any subsequent AWV.

At the conclusion of the AWV, each patient is provided with a written summary of health promotion suggestions, such as dietary modifications or exercise and needed screening tests, such as mammogram, and vaccines. The requirements of the AWV set minimal expectations. Our physicians will use these visits to bet-ter understand other aspects of patients’ lives that may influence their ability to take care of themselves. AWVs provide clinicians with an understanding of patients’ needs beyond diagnosis and treatment, and including lifestyle issues that affect health. Prior to the ACA, health promotion and disease prevention services were provided without any compensation because the payment mechanisms were only designed to pay for the assessment and management of medical conditions, nothing more. Now the value of comprehensive primary care has been recognize in Medicare payment. Under the sponsorship of the Stoeckle Center and MGH Primary Care Administration, a team representing the physician com-munity, information technology, workflow design, revenue/billing and compliance produced materials for use in all the MGH adult primary care practices. This team reviewed in detail the published Medicare expectations, reformatted material in ways that are more intuitively accessible and readily actionable to both patients and their physicians, and proposed ways to incorporate the new Health Risk Assessment (HRA) questionnaires into workflow. Two workbooks were designed so as to ensure that these new patient care services were an integral part of individual practice-based innovation planning. The Stoeckle Center and MGH Primary Care Administration have actively promoted the use of these newly covered benefits in all MGH primary care practices. Furthermore, these changes in Medicare services provide the opportunity to readdress wellness services covered by commercial insurance. Most carriers still do not support combined wellness care and problem assessment and management. Our efforts with the Medicare patients will ultimately improve care for all patients.

ANNUAL WELLNESS VISITS FOR MEDICARE PATIENTS

The John D. Stoeckle Center for Primary Care Innovation Massachusetts General Hospital 50 Staniford St., Ninth floor Boston, Massachusetts 02114617.724.8824stoecklecenter@partners.orgwww.massgeneral.org/stoecklecenter

Annual Report: Fiscal Year 2012Editor: Julie J. Martin, MSFront cover photo credits, clockwise from top left: Paul Batista, Alyse Gause, Joshua TousterContributing staff members: Michael Barry, MD; Rebecca Berman, MD; Marya Cohen, MD; Susan Edgman-Levitan, PA;

Pat Gavin; John Goodson, MD; Annie Huppert, MPH; Bill Kormos, MD; Lauren Leavitt, MA; Kerry McBride; Allison Siegel, MPH; Leigh Simmons, MD, Charlotte WardThis Annual Report 2012 was written and produced by the Stoeckle Center and is available online at www.massgeneral.org/stoecklecenter

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CARE MANAGEMENT IMPROVES CARE FOR COMPLEX PATIENTSThe Integrated Care Management Program (iCMP) is a Partners High-Risk Program to support practices in provid-ing robust care management to complex, chronically ill patients with a Partners primary care provider. In conjunction with Partners & PCHI, and led by Kerry McBride, conference manager, the Stoeckle Center supports the new and existing iCMP care managers by providing them with a great variety of educational activities to improve their day-to-day interactions with this population, as well as other members of the care team. Faculty from across the network lead webinars and in-person train-ings for care managers, which focus on topics ranging from managing substance abuse to chronic disease management and motivational interviewing.

SHARED DECISION MAKING PROGRAM SHARES 10,000TH VIDEOThe Stoeckle Center’s Shared Decision Making Program, initiated as a small pilot in 2005 has joined forces with the new Health Decision Sciences Center. The goal of the program remains the same: to enhance patient decision quality and satisfaction with care by ensuring that the right patient receives the right treatment at the right time. Through support from our funder, the Informed Medical Deci-sions Foundation, Mass General promotes shared decision making by providing video decision aids to patients facing significant healthcare decisions.Our work this past year has demonstrated the ability of the program to thrive from the initial physician-driven, in-office, prescrip-tion process. Forty DVD decision aids are available to order through a patient’s elec-tronic medical record. These decision aids present balanced, unbiased information on a particular health condition or treatment so that patients can actively participate in their own care, ensuring their values and preferences are taken into account. Patient feedback demonstrates the value these video programs provide in improving patient knowledge and satisfaction.

Our most popular programs continue to be those on cancer screening and disease management. We recently surpassed our 10,000th video order and average 350 programs prescribed monthly, More than 450 clinicians have participated in training sessions, including our internal medicine residents. Recent enhancements to the shared decision-making process include a pre-visit model allowing patients to self-order programs prior to their annual well-ness visit; further expansion into specialty practices such as obstetrics & gynecology, breast cancer, and cardiology; and the launch of an electronic referral system that allows primary care physicians to mail video decision aids to patients at the time of referral to orthopedic specialists. Our team is now working to enhance our current clinical services and beginning new initiatives in online training modules for shared decision making and further expan-sion of the programs to provide patients with decision aids prior to scheduling a variety of surgical procedures.

REDESIGNING AND IMPROVING DEPRESSION CARE IN PRIMARY CARE With funding from the Patrick Carney Foundation and the PCHI System Im-provement Grant Program the Depres-

sion Collaborative Care program (DCC) achieved significant results and progress as the program solidified in 2012. Aiming to improve the recognition, treatment, and management of depression in primary care, the DCC program utilizes a col-laborative team, including an empowered patient, to actively manage depression. Over half of actively tracked patients saw greater than 50% improvement, one-third were clinically in remission at the time of their most recent depression score, and al-most all had seen at least a 10% improve-ment between their first and last scores.As the DCC program has evolved, we have achieved increased satisfaction of providers and care teams due to increased support for managing behavioral health issues in primary care. We have also observed high patient satisfaction with the program, and have “graduated” many participants from active management to active self-management and guidance of a relapse prevention plan. We were very pleased that the program received the De-partment of Psychiatry Clinical Innovation Award. And, we hope to provide a tangible model and lessons for use in application of the DCC program across the Partners network.

Decision aids, like the Shared Decision Making Program’s video programs, can assist patients and provid-ers in the decision-making process. This year, the five most-requested video programs are PSA (prostate-specific antigen), Peace of Mind (advance directives), Insomnia, Colon Cancer Screening, and diabetes.

I N N OVAT I O N

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R E S E A RC H

AHRQ CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (CAHPS III)Susan Edgman-Levitan, PA, continues to serve as the co-prin-cipal investigator of the Yale CAHPS team, which again helped the Partners HealthCare System and PCHI practices improve their patient experience of care scores. The CAHPS consortium also focused on supporting practices across the country in their implementation of the PCMH CAHPS survey, as well as with all CAHPS surveys and products. The CAHPS surveys are now the national standard for evaluating the patient’s experience of care in hospitals, nursing homes, home health agencies, dialysis centers, ambulatory practices, and Accountable Care Organiza-tions. The Yale/Harvard team successfully submitted a proposal to AHRQ for CAHPS IV (five years), and the new grant began in October 2012.

NIBIB POINT-OF-CARE TECHNOLOGY GRANTThe Stoeckle Center is working with CIMIT (Center for Innova-tion in Medicine & Integrated Technology) on a five-year grant to develop ideas for point-of-care technologies which can be helpful in the primary care setting. POC is defined as medical testing at or near the site of patient care (office or home) in a convenient, user-friendly way. Pregnancy tests and rapid strep throat tests are common POC examples. Effective use of POC tests means that results are available immediately, and the patient and physi-cian can make appropriate medical decisions, without waiting for results to come back from a lab.The Stoeckle Center conducted a needs assessment to learn what tests would be helpful in the primary care setting. Early in 2013, engineering labs and small businesses will be invited to submit proposals for point-of-care technologies that will respond to the needs assessment.

COMMONWEALTH FUND CASE MANAGEMENT GRANTWith support from The Commonwealth Fund awarded in July 2011, Clemens Hong, MD, Tim Ferris, MD, and Allie Siegel, MPH, have been engaged in research on high-risk care manage-ment in primary care for their grant, “Implementing Care Manage-ment for Complex Patients in Medical Homes: A Comparison of Models.”The project consisted of qualitative assessments of 18 leading primary care-based care management programs from across the country, including interviewing care managers and program leaders at each program to assess core attributes, key opera-tional characteristics, and best practices of leading programs in this emerging field. Preliminary findings were be presented at the SGIM Annual Meeting in May 2012, and Dr. Hong presented his research on the subject at a meeting of funders in November 2012. The final Commonwealth Fund report will present policy recommendations and begin the process of developing the sci-ence around care management for complex, high-cost patients.

NCQA PATIENT EDUCATION & HEALTH LITERACYSelf-management training empowers patients with chronic medical conditions to make day-to-day decisions about their conditions and improve their overall health. During the past year, Marya Cohen, MD, and Bill Kormos, MD, of the Stoeckle Center, have been gathering Mass General data and national practice-level information regarding patient self-management and education, with the hope of better preparing institutions for this required area of PCMH transformation. Focus groups and surveys at MGH, as well as in collaboration with the NCQA, are ongoing; data has been analyzed and is currently being submit-ted for publication.Judge Levin Campbell has provided the Stoeckle Center with a three-year gift to support primary care faculty; Marya Cohen is the first recipient of this gift, for which we are grateful.

“As modern medicine evolves and grows, primary care remains an indispensable link with patients. The Stoeckle Center’s search for new and better ways to tailor primary care to modern needs could not be more timely, nor could it be more essential.”

– Judge Levin CampbellStoeckle Center Supporter

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S TA F F NO T E S

ACCOLADES

• Bill Kormos:> Appointed Chief of the James Howard

Means Firm for the Department of Medicine

> Named Editor-in-Chief, Harvard Men’s Health Newsletter

• Karen Sepucha & Leigh Simmons: selected for and completed the Partners Clinical Process Improvement Leadership Program

AWARDS• Leigh Simmons received the following:

> Clinician Educator of the Year; Society of General Internal Medicine, New England Region

> Class Day Award for Clinical Instructor at MGH; Harvard Medical School Graduating Class of 2012

• Elizabeth Rider received the prestigious 2012 Nicholas Andrew Cummings Award from the National Academies of Practice, a national award given annually to an individual who “has made extraordinary and enduring contributions to interprofessional healthcare education and practice.”

• Clemens Hong was named a Hamolsky Junior Faculty Abstract Award Finalist for a presentation he gave at the SGIM Internal Medicine Meeting

GRANTS• Susan Edgman-Levitan: 2012-2017 AHRQ

Consumer Assessment of Healthcare Providers and Systems (CAHPS IV)

• Leigh Simmons: 2012-2013 Picker Institute/Gold Foundation GME Challenge Grant, Shared Decision Making in Medication Prescriptions: Improving Communication Skills and Professionalism for Internal Medicine Residents.

PAPERS & PUBLICATIONS• Barry MJ, Meleth S, Lee JY, et al. Effects

of increasing doses of saw palmetto extract on lower urinary tract symptoms: a randomized trial. JAMA 2012; 306:1344-1351.

• Fowler FJ Jr, Gallagher PM, Bynum JP, Barry MJ, Lucas FL, Skinner JS. Decision-making process reported by Medicare patients who had coronary artery stenting or surgery for prostate cancer. J Gen Intern Med 2012; 27:911-916.

• Wilt TJ, Brawer BK, Jones KM, Barry MJ, et al. Radical prostatectomy versus observation for localized prostate cancer. NEJM 2012; 367:203-213.

• Volandes A, Paasche-Orlow MK, Mitchell SL El-Jawahri A, Davis AD, Barry MJ, et al. Randomized controlled trial of a video decision support tool for cardiopulmonary resuscitation decision making in advanced cancer. J Clin Oncol 2012 (in press).

• Barry MJ, Edgman-Levitan S. Shared decision making-pinnacle of patient-centered care. New Engl J Med 2012; 366:780-781.

• Barry MJ. Commentary: Too much information? Hastings Cent Rep 2012; 42:4.

• Hoffman RM, Barry MJ, Roberts RG, Sox HC. Reconciling primary care and specialist perspectives on prostate cancer screening. Ann Fam Med 2012; 10:568-571.

• Rebecca Berman, Camille Powe, Julia Carnevale, Andrew Chao, Janine Knudsen, Anthony Nguyen, Susan Edgman-Levitan. The crimson care collaborative: a student-faculty initiative to increase medical students’ early exposure to primary care careers and clinic operations. Acad Med 2012 May;87(5):651-5.

• Cohen MJ, Shaykevich S, Cawthon C, Kripalani S, Paasche-Orlow MK, Schnipper JL. Predictors of medication adherence postdischarge: the impact of patient age, insurance status, and prior adherence. J Hosp Med 2012 Jul-Aug;7(6):740-5.

• Zuckerman KE, Wong A, Teleki S, Edgman-Levitan S. Patient experience of care in the safety net: current efforts and challenges. J Ambul Care Manage 2012 Apr-Jun;35(2):138-48.

• Leape LL, Shore MF, Dienstag JL, Mayer RJ, Edgman-Levitan S, Meyer GS, Healy GB. Perspective: a culture of respect, part 1:

Below is a selective list of Stoeckle Center staff accolades and awards, presentations and publications, and more.

Michael Barry, MD Medical Director

Rebecca Berman, MD Founder, Crimson Care

Marya Cohen, MD Physician Researcher

Susan Edgman-Levitan, PA Executive Director

Sandra Feibelmann, MPH Project Manager

Sharon Floramo Administrative Assistant

Patricia Gavin Business Manager

John Goodson, MD Executive Secretary, Stoeckle Center Advisory Board

Sarah Hewitt Clinical Research Coordinator

Clemens Hong, MD Physician Researcher

William Kormos, MD Director of Education

Lauren Leavitt, MA Senior Research Coordinator

Julie Martin, MS Director of Communications and Consumer Engagement

Kerry McBride Conference Manager

Janice Neville Administrative Assistant

Elizabeth Rider, MSW, MD Director of Programs for Communication Skills

Karen Sepucha, PhD Director, Shared Decision Making Programs

Allison L. Siegel, MPH Project Manager

Leigh Simmons, MD Physician Researcher

Christine Sinsky, MD Consultant

John D. Stoeckle, MD Friend and Mentor

Charlotte Ward, MPH Systems Analyst

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The nature and causes of disrespectful behavior by physicians. Acad Med 2012 Jul;87(7):845-52.

• Frongillo M, Feibelmann S, Belkora J, Lee C, Sepucha K. Is there shared decision making when the provider makes a recommendation? Patient Educ Couns 2013; 90: 69-73. 2012 Sep 19. [Epub ahead of print].

• Sepucha KR, Belkora JK, Chang Y, Cosenza C, Levin CA, Moy B, Partridge A, Lee CN. Measuring decision quality: psychometric evaluation of a new instrument for breast cancer surgery. BMC Medical Informatics and Decision Making 2012; 12(1):51 [Epub ahead of print]. DOI: 10.1186/1472-6947-12-51.

• Sepucha KR, Feibelmann S, Abdu WA, Clay CF, Cosenza C, Kearing S, Levin CA, Atlas SJ. Psychometric evaluation of a decision quality instrument for treatment of lumbar herniated disc. Spine 2012; 37 (18); 1609-1616. DOI: 10.1097/BRS.0b013e3182532924.

• Simmons, LH, and Sepucha, KR. Resources for shared decision making, SGIM Forum 2012; 35(5): 10, 13.

• Rider EA. Advanced communication strategies for relationship-centered care. Pediatric Annals 2011;40:447-453.

• Swartz J, King HS, Rider EA. Behavioral health screening and referral in the pediatric office. Pediatric Annals 2011;40(12):610-616.

• Grant RW, Ashburner JM, Hong CS, Chang Y, Barry MJ, Atlas SJ. Defining patient complexity from the primary care physician’s perspective. Ann Intern Med 2011; 155 (12): 797-804.

• Grant RW, Wexler DJ, Ashburner JM, Hong CS, Atlas SJ. Characteristics of “complex” patients with type 2 diabetes mellitus according to their primary care physicians. Arch Intern Med 2012 May 28;172(10):821-3.

• Wang EA, Hong CS, Shavit S, Sanders R, Kessell E, Kushel MB. Engaging individuals recently released from prison into primary care: A randomized trial. Am J Public Health 2012 Sep: 102 (9): e22-e29. Epub 2012 July 19.

ORAL PRESENTATIONSMichael Barry, MD

• Early Detection of Prostate Cancer: Where are we in 2012? Medicine Grand Rounds, Newton-Wellesley Hospital

• You’re Talking to Me? Ensuring Patient Comprehension and Motivation. Invited Panelist, Partners HealthCare Connected Health

• Decision Aids in the Real World. Dartmouth Summer Institute for Informed Patient Choice, Invited Speaker

• Men’s Health: Early Detection of Prostate Cancer 2012. American College of Physicians. Massachusetts Chapter Scientific Meeting, Invited Speaker

• A Reporter’s Guide to Medical Decision Making. Health Journalism, Atlanta, GA

• Evidence Based Clinical Pearls: Prostate Cancer Screening. SGIM 35th Annual Meeting, Orlando, FL

• Shared Decision Making in the Real World: Effectiveness and Generalizability. The World Leadership Congress 2nd Annual Leadership Summit on Shared Decision Making, Newton, MA

• What Decision Makers Need: Decision Aids for Patients to Incorporate Comparative Effectiveness Research. The 4th Annual Comparative Effectiveness Summit, Washington, DC

• Complementary and Alternative Medicine for Urological Symptoms (CAMUS) Study. National Advisory Council for

Complementary and Alternative Medicine. NIH, Bethesda, MD

• The Quality and Safety Imperative for Involving Patients in Healthcare Decisions. Australian Disease Management Association. Melbourne, Australia, Invited Plenary Speaker

• Results of the Prostate Cancer Intervention Versus Observation Trial (PIVOT): What are the Implications for Screening? The University of Sydney School of Public Health. Sydney, Australia, Invited Speaker

Marya Cohen • The Effect of Smoking on Diabetic

Peripheral Neuropathy: a Systematic Review and Meta-analysis / National SGIM Meeting, Orlando, FL

Susan Edgman-Levitan, PA• “Through the Patient’s Eyes: Improving the

Patient’s Experience for Quality and Safety.” Care Experience Committee, McLean Hospital, Boston, MA

• Improving Patient Safety: Through the Eyes of the Patient. VHA Clinical Leadership Conference, Miami, FL

• Designing the Best: Engaging Stakeholders in Primary Care Transformation. Institute for Healthcare Improvement, 13th Annual International Summit on Improving Patient

STA FF N OT ES

Phot

o: A

lyse

Gaus

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Members of the Stoeckle Center, Partners in Care Team, and MGH Women’s Health Associates connect at a Knowledge Sharing Dinner.

15

Care in the Office Practice and Community, Washington, DC

• Patient Centered Health Care Systems: How Will We Know One When We See It? National Quality Forum Annual Conference, Washington, DC, Keynote

Clemens Hong • Complexity from the Physician’s

Perspective: Development and Validation of a Predictive Model to Identify Patients Who Physicians Define as Complex. National Society of General Internal Medicine Meeting

• How Much Does Panel Composition Influence Physician Performance Ranking on Patient Experience of Care Quality Measures? Academy Health Annual Research Meeting

Bill Kormos, MD• Teaching Evidence-based Medicine in the

Outpatient Setting. Patient Doctor II Faculty Retreat, Harvard Medical School

Leigh Simmons, MD• Shared Decision Making Education and

Training: The Massachusetts General Hospital Experience. Foundation for Informed Medical Decision Making Annual Medical Editors Meeting, Boston, MA

• Creating the Infrastructure to Successfully Adopt a Shared Decision Making Process. Panel Moderator. World Congress Leadership Summit on Shared Decision Making, Newton, MA

Charlotte Ward, MPH• How Much Does Patient Panel Composition

Influence Physician Performance Ranking on Patient Experience of Care Quality Measures? Northeast Regional SGIM Meeting, Portland, ME, and Academy Health’s Annual Research Meeting, Orlando, FL

• Relationship between Patient Experience of Care and Physician Productivity Measures. National SGIM Meeting, Orlando, FL

Crimson Care Collaborative• Crimson Care Collaborative: Disparities in

Healthcare Access Under Universal Coverage. Society of Student Run Free Clinics Conference, Long Beach, CA

• The Chelsea Partnership Clinic: Integrating Medical, Mental, and Social Healthcare for Post-incarceration and Urgent-care Patients. Society of Student Run Free Clinics Conference, Long Beach, CA

• Measuring Patient Experience to Improve Quality of Care in a Student-Faculty

Collaborative Practice. Society of General Internal Medicine, 2012 New England Regional Meeting, Portland, ME

POSTER PRESENTATIONS• Simmons L, Leavitt L, Greipp C, and

Sepucha, K. A Survey of Primary Care Clinicians on Use of Decision Aids and Confidence in Shared Decision Making Skills. Society of General Internal Medicine New England Regional Conference, Portland, ME, and National Conference. Orlando, FL

• Simmons L, Sepucha K, and Leavitt L. An Educational Program in Shared Decision Making in Primary Care Practice for Internal Medicine Residents. Medical Education Day, Harvard Medical School, Boston, MA

• Lee C, Olszewski A, Heintz J, Knudsen J, Lopez O, Zayas L, Hunter M, Shtasel D, Cohen M. Integration of Mental Health and Primary Care Services in a Student-faculty Collaborative Primary Care Clinic: an Approach for Psychiatry Education. American Psychiatric Association 165th Annual Meeting. Philadelphia, PA; and Society of General Internal Medicine Annual Meeting, Orlando, FL

• Knudsen J, Huppert L, Dempsey K, Donelan K, Berman R. Using Research to Demonstrate Quality of Care and to Improve

Quality in Student-Led Clinics. Society of General Internal Medicine, Annual Meeting. Orlando, FL

• Bollman B, Knudsen J, Mallampati D, Cunningham J, Ticona L, Lee C, Hoy J, Heintz J, Chatterjee P, Jastrzembski B, Tilahu H, Atkins E, Xerras D, Collins J, Bender-Ignacio R, Hong C, Wakeman S, Shtasel D, Lopez O, Hunter M, Edgman-Levitan S, Berman R, Olson K, Lee P, Cohen M. The Chelsea Partnership Clinic: integrating medical, mental, and social health care through a student-resident-faculty collaborative. Harvard Medical School Center for Primary Care 2011 Innovation Conference, Boston, MA

• Knudsen J, Bollman B, Mallampati D, Cunningham J, Ticona L, Lee C, Hoy J, Heintz J, Chatterjee P, Jastrzembski B, Tilahu H, Atkins E, Xerras D, Collins J, Bender-Ignacio R, Hong C, Wakeman S, Shtasel D, Lopez O, Hunter M, Edgman-Levitan S, Berman R, Olson K, Lee P, Cohen M. Developing a student-resident-faculty clinic: the Chelsea Partnership Clinic. Poster presentation, Harvard Medical School 2011 Medical Education Day, Boston, MA

S TA FF N OT ES

More than 450 Harvard Medical School students have volunteered to work with the Crimson Care Collaborative. Here, they gather at one of the many conferences where they presented their work.

www.massgeneral.org/stoecklecenter

Happy Birthday, Dr. Stoeckle!