The Healthcare Team as the Healthcare Provider: A Different View of the Patient Centered Medical...
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The Healthcare Team as The Healthcare Team as the Health Care the Health Care Provider Provider A Different Perspective on the A Different Perspective on the Patient Centered Medical Home Patient Centered Medical Home James Dom Dera, MD, FAAFP James Dom Dera, MD, FAAFP 23 April 2010 23 April 2010
The Healthcare Team as the Healthcare Provider: A Different View of the Patient Centered Medical Home
Presentation to the Ohio State Society of Medical Assistant's annual convention about the Patient Centered Medical Home and the role of the medical assistant
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1. The Healthcare Team as the Health Care Provider A Different
Perspective on the Patient Centered Medical Home James Dom Dera,
MD, FAAFP 23 April 2010
2. Objectives
Describe the current structure of the healthcare team
List to problems inherent to the current model
Define the concept of the healthcare team
Define and describe the PCMH
3. Conflicts of Interest
None
4. Preventive Medicine Behavioral Health Medical Assistants
Medication Refills Acute Care Nursing Case Manager Test Results
Chronic Disease Monitoring Physician
Prevention of secondary complications: CAD, CKD, PAD, etc.
7.
8. IOMs Crossing the Quality Chasm
10 Rules
Care based on continuous relationships
Customized based on the patients needs
Patient is in control
Shared knowledge
Evidence Based
Safe
Transparent
Anticipates patients needs
Decrease in waste
Cooperation amongst clinicians
6 Aims
Safe
Effective
Patient-Centered
Timely
Efficient
Equitable
9. Example
Mr. Jones is 78 year old male with multiple medical problems,
including BPH with recurrent UTI's, mild cognitive impairment, and
a poor support system. He calls the office to complain of dysuria.
He is offered an appointment three days later with another
physician in the practice.
After a review of his medical record, the MD gathers a history
and physical, performs a urinalysis, diagnoses a UTI, and
prescribes a course of Cipro.
Three days later the patient is in the hospital's intensive
care unit for a coagulopathy secondary to an interaction between
Cipro and warfarin (which the prescribing MD was unaware he was
on).
What Went Wrong?!!
10. What went wrong .... plenty!
Patient Safety
Debate exits about the numbers of errors per year that occur in
the health care system. Some put it as high as 20% to 50% of
encounters.
In this instance: ciprofloxacin and warfarin strongly
interact
Communication between physicians
This patient had a history of being unable to manage his own
medications, and FP warned cardio
The cardiologist re-started warfarin despite the patient's
primary care MD's previous warning.
11. continued
Anticipation of need
Is this patient safe for warfarin?
This patient has frequent UTI's other therapies more
appropriate?
Support system?
Patient control
Should this patient have to wait three days?
Should this patient have to see another MD?
12. Preventing examples like this requires a fundamental change
in how healthcare is delivered.
13. Patient Centered Medical Home (PCMH)
Definition #1: a single source of medical information about a
patient [including] a partnership approach with families to provide
primary health care that is accessible, family-centered,
coordinated, comprehensive, continuous, compassionate, and
culturally effective
Definition #2: a model for care provided by physician practices
aimed at strengthening the physician-patient relationship by
replacing episodic care based on illnesses and patient complaints
with coordinated care and a long-term healing relationship
14. PCMH definition (continued)
Another Definition: A patient-centered medical home integrates
patients as active participants in their own health and well-being.
Patients are cared for by a personal physician who leads the
medical team that coordinates all aspects of preventive, acute and
chronic needs of patients using the best available evidence and
appropriate technology. These relationships offer patients comfort,
convenience and optimal health throughout their lifetimes
15. Huh???
16. IOMs Crossing the Quality Chasm
10 Rules
Care based on continuous relationships
Customized based on the patients needs
Patient is in control
Shared knowledge
Evidence Based
Safe
Transparent
Anticipates patients needs
Decrease in waste
Cooperation amongst clinicians
6 Aims
Safe
Effective
Patient-Centered
Timely
Efficient
Equitable
17. Core Features of the PCMH
Personal Physician
Physician Directed Medical Practice
Whole Person Orientation
Care is Coordinated and/or Integrated
Quality and Safety
Enhanced Access
Health Information Technology (HIT)
Payment Reform
18. Personal Physician
Each patient has an ongoing relationship with a personal
physician trained to provide first contact, continuous and
comprehensive care
19. Physician Directed Medical Practice
The personal physician leads a team of individuals at the
practice level who collectively take responsibility for the ongoing
care of patients
From FPM in 2009 Ten Steps to a Patient-Centered Medical
Home:
HIRE MORE MEDICAL ASSISTANTS!!
20. Whole Person Orientation
The personal physician is responsible for providing for all the
patients health care needs or taking responsibility for
appropriately arranging care with other qualified
professionals.
This includes care for all stages of life; acute care; chronic
care; preventive services; and end of life care
21. Coordinated & Integrated Care
Across all elements of the complex health care system (e.g.,
subspecialty care, hospitals, home health agencies, nursing
homes)
The community (e.g., family, public and private community-based
services).
22. Quality and Safety
Evidence-based medicine and clinical decision-support tools
guide decision making
Physicians accept accountability for quality improvement
through voluntary performance measurement and improvement
Patients participate in decision-makingandfeedback is sought to
ensure patients expectations are being met
IT is utilized to support optimal patient care, performance
measurement, patient education, and enhanced communication
Patients and families participate in quality improvement
activities at the practice level
23. Enhanced Access
Through systems such as open scheduling and expanded hours
New options for communication between patients, their personal
physician, and practice staff
Internet Visits
E-mail
Group Visits
24. Health Information Technology (HIT)
CPOE
CDSS
EBM guideline integration
Health Exchanges
Electronic Prescribing
Practice based research, registries, quality improvement
25.
26. Wellness Illness Health Risk Disease Impairment Treatment
and Rehabilitation (Tertiary Prevention) Early Detection & Case
Finding (Secondary Prevention) Health Promotion & Protection
(Primary Prevention)
27. Health Care Costs Concentrated in Sick Few 1% 5% 10% 55%
69% 27% Source: A.C. Monheit, Persistence in Health Expenditures in
the Short Run: Prevalence and Consequences, Medical Care 41,
supplement 7 (2003): III53III64. Distribution of Health
Expenditures for the U.S. Population, By Magnitude of Expenditure,
1997 50% 97% $27,914 $7,995 $4,115 $351 Expenditure Threshold (1997
Dollars)
28. Payment Reform
NOW: Volume Based Payment (a.k.a. fee for service)
FUTURE: Value Based Payment; mix of:
Payment for case management
Fee-for-service
Payments for achieving measurable and continuous quality
improvements
29. CMA Where does the CMA fit into this? Coordination of Care
Enhanced Access Physician Directed Healthcare TEAM Whole Person
Orientation Quality/Safety
30. Origins of the PCMH
AAP 1967 introduced the concept of the medical home by posing
the following "Wherever the child is cared for, the question should
be asked, Where is the childs medical home? and any pertinent
information should be transmitted to that place"
WHO 1978 established some principles of the medical home and
the need for primary care
IOM 2001 the Chasm Report
FFM 2002 to 2004, highlighted the importance of family medicine
to this concept
31. Evidence for the PCMH
An increase in one primary care physician per 10,000 persons
results in 1.44 fewer deaths
Adults with a primary care physician rather than a specialist
had 33 percent lower costs of care and were 19 percent less likely
to die (after adjusting for demographic and health
characteristics)
RAND / UC Berkeley looked at care according to PCMH principles.
For almost 4,000 patients they found that:
Patients with diabetes had significant reductions in
cardiovascular risk
CHF patients had 35% fewer hospital days;
Asthmatics and diabetics were more likely to receive
appropriate therapy
32. PCMH Bottom Line
The PCMH would be responsible for all of the patients health
care needs acute care, chronic care, preventive services, and end
of life care working with teams of health care professionals. The
PCMH would coordinate the care of its patients with specialists,
lab/x-ray facilities, hospitals, home care agencies, and all other
health care professionals on the patient care team.
The PCMH would adopt the principles of patient-centeredness:
allowing patients free choice of physician, providing prompt
appointments, reducing waiting times, delivering care based on the
best evidence on clinical effectiveness, empowering patients to
partner with their personal physicians on decision-making, and
providing care in a culturally and linguistically appropriate
manner.
The PCMH would use health information systems to provide data
and reminder prompts such that all patients receive needed
services.
33. PCMH Bottom Line
Care delivered by primary care physicians in a Patient-Centered
Medical Home is consistently associated with better outcomes,
reduced mortality, fewer preventable hospital admissions for
patients with chronic diseases, lower utilization, improved patient
compliance with recommended care, and lower Medicare spending.
34. Preventive Medicine Point of Care Testing Chronic Disease
Monitoring Medication Refills Test Results Acute Care Behavioral
Health Mid-Level Provider Acute Mental Health Complaint Chronic
Disease Compliance Barriers Provider Physician Medical Assistant
Preventive Medicine Behavioral Health Medical Assistants Medication
Refills Acute Care Nursing Case Manager Test Results Chronic
Disease Monitoring Physician
35. Preventive Medicine Point of Care Testing Chronic Disease
Monitoring Medication Refills Test Results Acute Care Behavioral
Health Mid-Level Provider Acute Mental Health Complaint Chronic
Disease Compliance Barriers Provider Physician Medical
Assistant
36. Other Examples
ACO
integrated health care delivery system that relies on a network
of primary care physicians, one or more hospitals, and
subspecialists to provide care to a defined patient population
