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					  ThePatient-centered Medical Home and
   the Future of American Medical Care

          Ed Wagner, MD, MPH, MACP

    MacColl Institute for Healthcare Innovation
        Group Health Research Institute

   Primary Care — Will It Survive?

                                 doesn t
        And will it matter if it doesn’t

Percentage of medical students choosing
        primary care specialties




           Family    General Internal   Pediatrics
          Medicine      Medicine

        What’s Threatening Primary Care?

 • Changing demography
   and practice content
   increasing demand
 • Greater care complexity
   and ? lower provider self-
 • Declining real income
 • Working harder and
   harder just to keep up

            Greater care complexity and
                ? lower self-efficacy
Number of Chronic Conditions per Medicare Beneficiary

 Number of              Percent of           Percent of
 Conditions             Beneficiaries        Expenditures
            0                     18                1
            1                     19                4
            2                     21                11
            3                     18                18
            4                     12                21
                                       63%               95%
            5                     7                 18
            6                     3                 13
           7+                     2                 14

 Changing demography and practice content
  Proportion of Office Visits for Chronic Illness
               Care by Age - 2005

                         Chronic Problem,    Chronic Problem,
                             Routine             Flare-up
      All patients             30%                  9%

      Age 25-44                 26%                9%
      Age 45-64                 37%               10%
       Age 65+                  42%                11%

  NAMCS, Advance Data No. 387, 2007

  Greater care complexity and efficacy,
      but with lower self-efficacy?
  Multiple Medications                      Complex Guidelines

         Self-management Support

 Greater care complexity and ? lower

  • Ostbye et al.* estimate that it would take 10.6
    hrs/working day to deliver all evidence-based care for
    panel members with chronic conditions
  • “These excessive demands contribute to long waiting
    times and inadequate quality of care for patients.”
    [Bodenheimer, NEJM, 2006]
  • IM and FM residents report that a lack of confidence in
    one’s ability to manage complex, chronically ill patients
    is driving career choice away from primary care.

  *Ostbye et al., Ann Fam Med 2005; 3:209

          Current Chronic Illness Care

  • Patients with major chronic illnesses receive
        recommended care about ½ the time
  •These deficits are now perceived by patients, physicians
                      and policy-makers
                               Percent agreement
                         Public Physicians Policymakers

People with chronic         48%             45%           22%
conditions usually
receive adequate
medical care

                      What to do?
• The future of primary care (and our healthcare system)
  depends upon its ability to improve the quality and
  efficiency of its care for the chronically ill
• It will also require a recommitment of primary care to
                                  timely, patient-centered,
  meet the needs of patients for timely patient centered
  continuous and coordinated care
• That will require a major transformation or redesign of
  primary care practice, not just better reimbursement
• But such transformations will be difficult to motivate or
  sustain without a financial investment in primary care.

          What are the key features of a
         Patient-Centered Medical Home?
ACP, AAFP, AAP, AOA joint statement
•   Personal Physician – 1st contact, continuous, comprehensive care
•   Team Care – collectively take responsibility for ongoing care
•   Whole Person Orientation – take responsibility for all patient needs
    by delivering or arranging care
•   Coordinated Care – across all elements of the healthcare system
•   Quality and Safety – by implementation of CCM, continuous QI, and
    voluntary recognition process
•   Enhanced access – via open scheduling, expanded hours and new
    options for communication
•   Payment – recognizes value of the PCMH, pays for coordination and
    electronic communication with patients, , supports IT use,

       Commonwealth Fund Medical
      Home in the Safety Net Program

• Early step was to develop a “change
  package” that defines the attributes of a
  PCMH, and the system changes needed to
  get there.
• Assembled national experts to review and
  amend draft changes.
• Amended change package reviewed and
  edited by Washington state multi-
  stakeholder group.

        What are the key features of a
       Patient-Centered Medical Home?
   Commonwealth Safety Net Medical Home Initiative

• Engaged leadership
• Quality improvement strategy
• Empanelment (linking each patient with a provider)
• Enhanced access
• Continuous, team-based healing relationships
• Patient-centered interactions
• Organized, evidence-based care
• Care coordination

                          Ms. G
Ms. G is a 48 yo. single mother of three teen-agers who
does domestic work. She is uninsured and receives her
care at a public hospital clinic. She has a BMI of 37, has
poorly controlled diabetes, and painful osteoarthritis of
her knees. She is chronically depressed and has required
Opioids to control her knee pain. She frequently misses 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’s Medical Care

Continuity and       She sees whoever has an appt. available that day.
                     MDs have no defined team.
Team-based care
                     No evening or weekend appts. make it difficult for
Access               her to work and keep appts.
                     The clinic was unaware that she went to ED with
Coordination         symptoms of CHF and was admitted. She was
                     readmitted 3 weeks after discharge having had no
                     outpatient care.
Patient-centered     No trained self-management support. She often
                     doesn’t understand what the MDs tell her to do.

                    Ms. G’s Care

Organized,         Care delivered in brief, reactive visits. Her no-
                   shows make it hard to titrate meds. No staff
Evidence-based     available to provide more intensive follow-up.
                   No effort to link patients with primary care
Empanelment        teams. Despite poor disease control and missed
                   appts, p
                    pp , practice has never tried to initiate a visit.
                   Leadership preoccupied with financial status
Quality            Performance measurement limited to required
                   reports. Occasional QI project.

Aren’t we are all medical homes—
                  What’s New?

Commonwealth Survey of Americans 18-64

• Medical home defined by the following:
  1. Has a regular source of care.
  2. It is not difficult to contact the provider
  by telephone.
  3. It is not difficult to get care or advice after hours.
  4. Office visits are generally well organized and
  running on time.
• Only 30% report having a MH
• Hispanics, the uninsured, and CHC patients less
  likely to have a MH.

        Commonwealth Survey of Americans 18-64
        What’s the impact of a MH on getting patient
                       needs met?

               Percent of adults always getting the care they need
                                when they need it.
                        Medical Home          Regular source             No regular
                                              of care, not MH          source of care

        Commonwealth Survey of Americans 18-64
       What’s the impact of a MH on chronic disease

                    Percent of adults with hypertension who regularly check
                                 BP        and BP is controlled






                            Medical Home             Regular source of care, not

  Commonwealth Survey of Primary Care MDs: 2006

     • Only 28% of US MDs have an EMR compared to 90% in the
       Netherlands, UK, and New Zealand

     • Only 37% of US MDs have the capacity to generate a list of patients
       with a disease or generate a drug list compared with the majority of
       MDs in other developed countries.

     • Less than 50% of US MDs have data on the quality of their care

     • Only 30% of US MDs use multidisciplinary teams compared to 81%
       in UK

     • Only 37% of US MDs routinely get information back after referring a
       patient to a specialist

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Are Medical Homes:
   • A fad?
   • A rationale for better payment?
   • Life support for primary care?
   • What patients want and need?

Health Partners Medical Group
   • Better care coordination centered in the primary
     care medical home

   • Proactive chronic disease management through
                                    g            g
     phone, computer, and face-to-face coaching.

   • More convenient access to primary care
     through online scheduling, test results, email
     consults, and post-visit coaching.

Grumbach, Bodenheimer, Grundy: The Outcomes of Implementing PCMH 2009

Bestcare results
   • 129% increase in patients using optimal diabetes

   • 48% increase in patients receiving optimal heart
     disease care.

   • 350% reduction in appt waiting time
   • 39% decrease in Emergency room visits

   • 24% decrease in admissions

Grumbach, Bodenheimer, Grundy: The Outcomes of Implementing PCMH 2009

Genesee Health Plan
   • Set-up:

        – Four year longitudinal evaluation of PCMH to serve
          25,000 uninsured adults in Flint, Michigan.

        – Team approach to improve health and reduce costs
        – Health Navigator works with primary care clinicians
          to support patients to:
             • Adopt healthy behaviors
             • Improve chronic and preventive care
             • Link to community resources
Grumbach, Bodenheimer, Grundy: The Outcomes of Implementing PCMH 2009

Genesee Health Plan results
   • 72% of all uninsured adults in the county can now
     identify a primary care practice as their medical home.
   • 137% increase in mammography screenings
   • 36% reduction in smoking and “improvements in other
     healthy behaviors.”
   • 50% decrease in ER visits
   • 15% fewer inpatient hospitalizations
   • Total hospital days per 1,000 enrollees now cited as
     26.6% lower than competitors.
Grumbach, Bodenheimer, Grundy: The Outcomes of Implementing PCMH 2009

SouthCentral Foundation Alaska
   • Relationship drives structure & process

   • Panel size 1200

   • Finance goals aligned with good care

   • Highly supported primary care team

   • Advanced access

   • Significant investment in training – initial and ongoing

       Gottilieb, Sylvester, Eby (January 2008). Transforming your
       Practice: What Matters Most. Family Practice Management

SCF success since beginning
changes in 1999

 • Each year the population served increases 7% but the funding
   increases only 2% with the following results of these methods.

     – A 40% decrease in urgent care and ER use, a 50% decrease
       in specialist use, and a 30% decrease in hospital days are
       attributed to the relationship-based approach, same-day access
       and better management of chronic conditions.

     – Clinical quality data from Medicaid children showed “perfect
       care” 85% of the time for children with asthma (from 35%),

     – HIV positive hospital admissions went from 22% to 8%,

     – Childhood immunizations went from 85% to 94%.

     – By implementing same-day access they reducing the
       behavioral health wait-list form a back log of 1,300 to zero in

Factoria: Group Health
 • Reduced panel size, emphasized team care,
   and pre-visit planning

 • Extensive use of HIT for e-visits and population
   health management

 • Investment in care coordination and patient

 • Used LEAN to create culture of continuous

 Reid, Fishman, Yu, Ross, Tufano, Soman, Larson (September 2009). Patient-Centered Medical Home
 Demonstration: A Prospective, Quasi-Experimental Before and After Evaluation. The American Journal
                                   of Managed Care. Vol. 15, No. 9

Factoria Results

 • Patients rate practice as better on 6/7 pt experience

 • Less staff burnout:

 • PCMH patients had better overall quality composite

 • More email, PCP & specialty visits,

 • 19% fewer ED visits paid for added physician FTE

 • At 24 months reduction in overall costs

Geisinger Central PA
Interventions & environment
 • Comprehensive practice changes including advanced
   access, population management, use of I

 • Intervention emphasis on coordination and facilitation of
         investment in nurse care managers
   care, i    t   ti

 • Primary care & specialty on the same platform and
   under the same large financial umbrella

 • Shared savings rewards primary care

  Paulus, Davis, Steele (September/October 2008). Continuous Innovation
   in Health Care: Implications of the Geisinger Experience. Health Affairs.
                             Volume 27 Number 5

Geisinger Results
 • “Early evidence” showed a 19% reduction
   in “all cause” admissions to hospitals.
 • 7% decrease in overall cost

  The potential of the patient-centered
            medical home?

 • Make the practice of primary care less stressful and
   more rewarding.

 • Increase the quality of care and outcomes for
   i di id l with chronic conditions.
   individuals ith h i         diti

 • Reduce health care costs by keeping people out of the
   ER and hospital.

 • Convince medical students that complex, multi-problem
   patients can be effectively managed by primary care.

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PCMH practices:
• Determine and understand which patients should be
  empanelled in the medical home and link them with a
  provider and team.
• Use panel data and registries to proactively contact,
  educate, and track patients by disease status, risk
  status, etc.
• Understand practice supply and demand, and balance
  patient load accordingly.

Continuous and Team-Based Healing

PCMH practices:
• Clearly link patients to a provider and care team so both
  patients and provider/care team recognize each other as
  partners in care.
• Assure that patients are able to see their provider or
  care team whenever possible.
• Define roles and distribute tasks among care team
  members to reflect the skills, abilities, and credentials of
  team members.
• Cross-train care team members to maximize flexibility
  and ensure that patients’ needs are met.

         Engaged Leadership
PCMH leaders:
• Provide visible and sustained leadership in overall
  culture change as well as specific strategies to improve
  quality and spread and sustain change.
                                   g     y     g
• Establish a QI team that meets regularly and guides the
• Ensure that team members have protected time to
  conduct activities beyond direct patient care that are
  consistent with the medical home model.
• Incorporate the practice’s values on creating a medical
  home for patients into staff hiring and training

     Quality Improvement (QI)
PCMH practices:
• Choose and use formal models for quality improvement
• Establish and monitor metrics to evaluate improvement
  efforts and outcome and provide feedback
• Obtain feedback from patients/family about their
  healthcare experience and use information for quality
• Ensure that patients/family, providers, and care team
  members are involved in quality improvement activities.
• Optimize use of information technology

          Enhanced Access

PCMH practices:
• Promote and expand access; ensure that established
  patients have 24/7 continuous access to their care
  teams via phone, email, or in-person visits.
• Scheduling options are patient- and family-centered and
  accessible to all patients.
• Help patients attain and understand health insurance

           Care Coordination
 PCMH practices:
 • Link patients with community resources to facilitate referrals
   and respond to social service needs.
 • Provide care management services for high risk patients.
 • Have referral protocols and agreements in place with an array
   of specialists to meet patients’ needs.
 • Proactively track and support patients as they go to and from
   specialty care, the hospital, and the emergency department.
 • Follow-up with patients within a few days of an emergency
   room visit or hospital discharge.
 • Test results and care plans are communicated to

  Patient-Centered Interactions

 PCMH practices:
 • Assess and respect patient/family values and expressed
 • Encourage patients to expand their role in decision-
   making, health-related behavior change, and self-
 • Communicate with their patients in a culturally
   appropriate manner, in a language and at a level that the
   patient understands.
 • Provide self-management support at every visit through
   goal setting and action planning.

Organized, Evidence-Based Care

 PCMH practices:
 • Use planned interactions according to patient need.
 • Enable planned interactions with patients by having
   available,                                     standing
   available up-to-date patient information and “standing
   orders” for the care team before any interaction.
 • Use point-of-care reminders and other decision support
   based on clinical guidelines.
 • Assure access to care management resources to
   provide more intensive support to high risk patients


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