VA NWI & V23 Medical Home Pilot

Michael S. Hein, MD, MS, FACPMedical Director, VA Midwest Health Care Network, V23Primary Care and Specialty Medicine Service LineMinneapolis, MN

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Existing Outreach Clinics

Planned Outreach Clinics

VISN 23

VISN 23 Data Summary

• FTEE 11,196• Patients Served 290,485• Women Veterans Served 18,434• Outpatient Visits 2,514,579• Budget $1,987,592,774• Medical/Surgical Average Daily

Census (ADC) 300.2• Psychiatry ADC 52.2• Community Living Center ADC

560.5• Domiciliary ADC 181.9• PRRPT ADC 90.8

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• Health Care Systems 8

• CBOCs 44• Outreach Clinics 2• Vet Centers 14

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EOFY 08 VISN VetPop, Enrollment, Market Share and Patients

VeteranPopulation (Projected)

Enrollees(Actual)

Enrollment Based Market Share

(Enrollees to VetPop)

Patients(Actual)

1,025,564 384,225 36% 290,485

FY07 Enrollees and Patients Urban, Rural or Highly Rural

Enrollees Patients

Urban Rural Highly Rural

% Rural (R+HR)

Urban Rural Highly Rural

% Rural (R+HR)

139,082 224,465 26,084 64% 92,250 157,812 19,015 66%

Veterans

Nebraska-Western Iowa HCS

VA - Grand Island, Nebraska (Central) Integrated Health System (VANWIHCS) GRI, Omaha, Lincoln and 5 CBOC’s ~ 45,000 PCP

patientsRural Community – pop. 45,000Serves

Western and Central Nebraska Northern Kansas

Grand Island ~ 13,000 patientsAdditional services: Nursing Home, Therapy,

Mental Health, Residential Treatment, two CBOC’s, Pharmacy, Lab, Radiology

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Joint Principles of the Patient-Centered Medical Home

AAFP, AAP, ACP, AOA

Ongoing relationship with personal physician

Physician directed medical practiceWhole person orientationEnhanced access to careCoordinated care across the health systemQuality and safetyPayment

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Primary Care in the VA

EMR (CPRS) – Fully Integrated; ‘Paperless’Pharmacy Clinics – Clinical PharmacistsChronic Disease Management (Wagner Model)1.0 – 3.0 (2.2) PC Support Staff to 1.0 Provider

FTEUbiquitous Clinical Metrics, including HEDISCAHPS Satisfaction/Experience ScoresCosts – Pharmacy, Lab, Imaging, Clinical ServicesIntegrated (co-located) MH servicesPatients Assigned to PCP: Max Panel = 1200

Medical Home Pilot Time Frame

Conceived Spring of 2008 Proposal for local Innovation Grant – Approved Imbedded project into IHI Triple Aim – Phase II

June 2008, Team Formation and Planning Begins

September 1, 2008, PCMH Clinic ‘opens’Spread to next core teams – September 2009

Inspiration: Quality

Delvin McMillian, 28, a retired airman from Bessemer, Ala., spins away from his pursuers in a quad rugby game at the 28th National Veterans Wheelchair Games, held July 25 through 29

(2008) in Omaha, NE.Photo by David E. Klutho, Sports Illustrated

The Core Team (Micro-Clinic)

Clerks/Schedulers x 2LPN x 3 (4)RN x 1Providers x 5 (2.9 PC FTE)

3 x MD 1 x PA, 1 x APRN

~ 2,800 patientsStaffing ration = 2.0 to 2.3 FTE/PC FTE

The Team (clinic-wide)

Chronic Disease Management Nursing (Wagner)

EMR (CPRS) support staffData AnalystSocial Work*Clinical Pharmacy*Mental Health – partially integratedLeadership - Nursing, Administrative, ClinicalNewly added – Co-management Office

NWI

Core Team-1

(2800)

Core Team-2

(4200)

Core Team-3

(1000)

CBOC-NP

(3000)

CBOC-H

(2000)

Example Medical Home – NWI Grand IslandExample Medical Home – NWI Grand IslandExample Medical Home – NWI Grand IslandExample Medical Home – NWI Grand Island

HBPC

(75)

Clinical Microsystems GRI – Medical Home

(Approx. no. of Patients)

TEAM, SYSTEM REDESIGN, MEDICAL HOME PRINCIPLES

Approach

Constructing Exceptional Primary Care

Team Development and Function

Roles and ResponsibilitiesConflict ResolutionEffective and Safe CommunicationPersonalities – Strengths AssessmentDeveloping a Shared Charter/VisionWorking together

Planning, Implementation, System Redesign

Measurement of ‘Team’

System Redesign at the Front Line

PDSA Rapid Cycle ImprovementBasic LEAN principles – Flow mapping,

measuringWeekly Data Driven DecisionsOpen Access – Reinforcing principlesContinuous Panel ManagementWeekly (1-hr) Performance-based MeetingsData Acquisition and Presentation

Time

Pre-training and Education Weekly to bi-monthly ½ to 1 day sessions (3 months)

Weekly Team MeetingsQuarterly BreakoutsDaily Decisions

Care Management and Coordination Non-face to face care frees up some clinic time

Open Access Scheduling Continuously and rigorously applied

Daily Huddles

Performance

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The Use of Data

What you measure = how you will ActTimely – frequently enoughActionable – team knows what it meansAccurate – not flawless, but reasonable

Continuously Maturing

Measurement Is it measuring what you want to change? Is it sensitive enough to show change? Is it measuring patient-centered view, or health

system view?

Key Lessons Learned (ing)

Measuring Team Dynamic – Performance

Leadership Good Data in the Hands of

Good People High Performing Team

Dynamic – Limited/Cyclical Nutting et.al. NDP and

“Adaptive Reserve” Time – Commerce of the

Medical Home We Were not Patient-

Centered Enough

What’s Next – National/Regional

History of Primary Care in the VA – 10 year Pulling all of the pieces together

National and Regional (VISN) efforts Universal Services Task Force Report Care Coordination and Chronic Disease Management National Implementation System Redesign at the Front-line Team Dynamic and Function

What’s Next - Local

Spread2 patients on the Core Team weekly meetings

Or a patient council

Coordination of Care – Dual Care FocusContinuous Learning – Working in TeamMeasurement (drives change): Health, Cost,

Patient Experience Team Function/Dynamic “Hominess”

Unsolicited Advice

The principles of Medical Home should guide action

Create a multidisciplinary high performing team Share a Vision that is focused on Quality and Safety

Be knowledgeable about process, flow, and improvement science => gained efficiencies.

Pick the ‘low hanging fruit’ – measureInvolve patientsBe data drivenCelebrate SuccessesLearn, evolve, and don’t avoid ‘failure’

Advice"If you're not failing every now and again, it's a sign you're not doing anything very

innovative.“

Woody Allen

References

Nutting, P., et.al. Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home. Ann Fam Med 2009;7:254-260.

Reid, R.J., et.al. Patient-Centered Medical Home Demonstration: A Prospective, Quasi-Experimental, Before and After Evaluation. Am J Manag Care. 2009;15(9):e71-e87.

C00ley, W.C., et.al. Improved Outcomes Associated with Medical Home Implementation in Pediatric Primary Care. Pediatrics 2009;124;358-364.