11/8/2010 - ideal family healthcare · the role of population health management in the...
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Towards a Collaborative Care Delivery Model:Collaborative Care Delivery Model:
The Role of Population Health Management in the Patient‐Centered Medical Home
DMAA: The Forum10 Washington, DC.October, 2010
Darren Schulte, MD, MPP. EVP, Collaborative Care, AlereGreg Sharp, MD. Co‐Founder of Ideal Family Healthcare
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Who is Alere?
• Alere is a global leader in point‐of‐care rapid diagnostic testing and in personal health support solutions devoted to providing the most complete set of connected devices and solutions to empower individuals, their providers and payers to make smarthealthcare decisions
• A $2 billion company with 11 000 employees globally including• A $2 billion company with 11,000 employees globally, including over 2,200 healthcare professionals, and clients in all 50 U.S. states and worldwide
• Alere Health, the health management division of Alere, connects diagnostic and monitoring devices with health coaching and clinical outreach using health information technology to address the entire spectrum of health needs from preconception to palliative care
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New Allies in Health Care“Help me, help you”J M i (1996)
• Patient‐centric care models can provide a framework for collaborative alliances between physicians and population health mgmt organizations to improve quality and outcomes
‐Jerry Maguire (1996)
health mgmt organizations to improve quality and outcomes
• It’s a potential “win‐win” arrangement…
• But potential areas of collaboration will need to be tested to• But potential areas of collaboration will need to be tested to avoid further care fragmentation
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PCMH – What’s All the Buzz About?
• Strengthen and save primary care
• Improve chronic disease care
• Defragment patient care
• Emphasize consumerism• Emphasize consumerism
• Incorporate new technologies
Early successes have been observed related to quality gains, patient and provider satisfaction
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Healthy Primary Care = Quality Care
• Multiple studies conducted over last several decades observe that greater access to primary care results in:
* Fewer preventable ED visits and hospital admissions;* Fewer tests and lower costs; and * Less overtreatment
as compared with specialist driven care
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US Primary Care in Trouble
• Between 1997 and 2005, the number ofBetween 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50% 1
• In 2005, nearly 80% of internal medicine residents choose
Source:(1) N Engl J Med 2006; 355:861‐864
subspecialists or hospitalist careers1
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Lower Pay, Fewer Training PositionsPercentage change in number of year 1 residency positions (PY‐1) offered
from 1998 to 2008 vs 2007 income by specialtyfrom 1998 to 2008 vs 2007 income by specialty
Source: Arch Intern Med 2010;170:389‐390
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Less Time for Patients and Quality Care
Traditional, FFS model promotes a volume based practice ‐ described as “hamster health care”1
Source:(1) BMJ 2000: 321: 1541‐1542
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Recommended Care is Often Not Delivered
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“Tyranny of the Urgent”
• Care is provided within a 10 or 15 min time frame in which a physician attempts to address in order of priority:
1. acute, episodic care2. chronic disease mgmt 3. wellness and prevention
• The typical ambulatory care model is based largely upon reactive care
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Primary Care Facing Increasing Stress
• Over next 5‐10 years, more patients will seek primary care…
• Without structural and payment reforms to attract and retain generalists, access to quality primary care will continue to suffer
• Despite near universal coverage in Mass. following 2006 reform initiative, 1 in 5 adult residents reported difficulty obtaining primary care in 2009.1
Sources:(1) Health Affairs 2010: 29:6. 1234‐1241
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The PCMH – A Way Forward?
• Rebuild and strengthen primary care capacity
• Structural and payment reforms envisioned
• Coordinated, comprehensive, accessible care delivered within context of family and communitydelivered within context of family and community
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Joint Principles of a PCMH
• Adopted by major generalist societies (ACP, AAFP, AAP, AOA) p y j g ( , , , )in 2007:
1. Personal physician
2. Physician directed medical practice
3. Whole person orientationp
4. Integrated, coordinated care
5. Quality and safety emphasis
6. Enhanced access
7. Payment reform. ay e t e o
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From Principles to Practice…Annual Outcomes for Major Medical Home Demonstrations
PCMH Demonstration initiatives Hospital admits ER visits Total savings per pt
Colorado Medical Home for Children ‐ 18% NR $215
Geisinger Health ‐ 15% NR NR
Group Health Cooperative* ‐ 6% ‐29% No change (initial 18mo)$10 pmpm (>21 mo)
Intermountain Health Care ‐4.8% No change $640
North Carolina (CCNC) ‐40% (asthma pts only)
‐16% $516
North Dakota (MeritCare & BSBC ND) ‐6% ‐24% $530
Vermont Blueprint for Health ‐11% ‐12% $215
Sources: D. Fields, et. al. Health Affairs 2010; 29(5): 819‐826; Grumbach, et. al. The Outcome of Implementing a Patient Centered Medical Home Interventions. PCPCC Publication. Aug 2009 ; Reid, et al. Health Affairs 2010; 29 (5): 835‐843
Notes: * Compared with a control group; NR = not reported
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What Were the Essentials for Success?
• Dedicated non physician care coordinators
• Expanded provider access
• Effective health information technology – track patient issues, goals, recommended carep , g ,
– predictive modeling, risk profiling, decision support
– performance measurement
• Meaningful incentive payments– Hybrid models – FFS plus coordination and performance‐based
ffees
Source: D. Fields, et. al. Health Affairs 2010; 29(5): 819‐826
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Group Health Experience1
GHC il t d di l h il t t S ttl li i• GHC piloted medical home pilot at Seattle clinic (9,200 pts) in 2006
• Reduced average MD panel size
• Hired more clinical and ancillary staff
• Made greater use of virtual medicine, patient outreach and chronic care mgmt techniques
Source:
1. Health Affairs 2010; 29(5): 835‐843
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Group Health Experience (cont’d)
• Results after 12 months…
‐ Improved patient satisfaction and access
‐ Reduced provider burnout
• Positive experience based upon primary care investment, staff training and strong leadership, and use of patient centric electronic records
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It’s Harder than It Looks…
A successful medical home will require1
• Physicians to work within and lead care teams
• Expanded focus from one patient at a time to proactive practice panel mgmtproactive practice panel mgmt
• New practice organization and care delivery models
• Active use of evidence‐based decision‐support
Sources
(1) Ann FamMed 2009;7:254‐260.
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…And Physicians Aren’t Trained for This• Care team leadership
• Continuous quality improvement
• Population health management
• Health coaching and education
• Behavior change approaches
• Patient self management skill building
• Patient care goals and issue tracking & monitoring
• Community resource integration
• Clinical registries, evidence based alerts and reminders
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Health Management Industry Experience
• Wellness and disease mgmt programs have been widely accepted by health plans and employers as yielding quality improvement, productivity gains, and in many cases, overall cost savings
• But these organizations largely worked independently with patients rather than being integrated within or closely aligned with physician g y g p ypractices
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Addressing the Care Continuum
Wellness
Portal/HPA
Chronic CareAsthma
Care GapsDiagnosticScreening
Care Gaps
DiagnosticScreening
Portal/HPAHealth Coaching
OnlineScreening
Tobacco Cessation
Mind & Body
Wellness
DiabetesHeart FailureCADCOPDChronic Pain
Care Gaps
DiagnosticScreening
DiagnosticScreening
Care Gaps
Women & Children’s
PreconceptionOB Risk Assmt/EdOB Case Mgt/HomePerinatal screeningNICU
WellnessCase Management
OncologyComplex Care
Intensive CarePalliative Care
Personal Health Support
NCQA PPC-PCMH RecognitionCollaborative Care PlatformP4P / PQRI Support
Collaborative Care Solutions™
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PatientCentered Care
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Physicians & Coaches ‐ Reinforcing Roles
Skill Set Physicians & Nurses* Health Coaches*y
Provide Information Good Fair to Good
Stimulate Motivation Poor Good
Enhance Behavioral Skills Poor Good
* On average
• Physicians have perceived their job to offer health advice and treat disease, not motivate and change behavior
• Coaches are trained and expected to educate, build motivation and skills, and provide support in order to help individuals achieve their goals
On average
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• Working together, each at the “top of their license”, clinicians and coaches can be highly complementary and synergistic
Source:Adapted from Gordon Norman, MD. Healthcare Unbound Presentation, July 2010
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It Takes a Village…
• Medical homes are not enough without integration within aMedical homes are not enough without integration within a larger medical neighborhood
• Care fragmentation between generalists and specialists will mitigate PCMH gainsg g
• Most successful PCMH initiatives to date operated within an integrated delivery network, in which there was information sharing, accepted performance standards, and broad accountability
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An Ideal Health Ecosystem
li li i i h d• Aligns clinician, coaches, and other care providers caring for your health by being person‐centered
• Connects all the health care sites and silos
• Delivers
Convenience
Emphasis on proactive self‐care
Effective information, encouragement, and support
Coaching & Incentives
HealthAdvocacy
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Source:Adapted from Gordon Norman, MD. Healthcare Unbound Presentation, July 2010
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What Does a Partnership Look Like?
A fl ibl b dl f i d t h l i• A flexible bundle of services and technology is integrated within care delivery
– Practice panel mgmt assistance
– Decision support tools
– Health coaching, education, and patient self‐mgmt tools
– Promote treatment adherence
– Remote patient monitoring
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Ideal Family Healthcare
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Ideal Family Healthcare
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Ideal Medical Practices
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Patient‐Centered Medical Home
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Patient Centeredness
• The “spirit” of the Medical Home
• The critical role of time
• Respectful of patient desires and needs
• Take care not to add more to the model than patients want or providers can handle
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Continuity
Do you have one person or group that you think of as your personal
0
1.18N/A
Do you have one person or group that you think of as your personal doctor or healthcare team?
Pilot Ideal
0
0
90 47
8.45No
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100
90.47Yes
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Efficient for Patients
When you visit your doctor’s office how often is it well organized
0.50.29N/A
When you visit your doctor s office, how often is it well organized, efficient and not wasteful of your time?
Pilot Ideal
1
0
0
12
1.52
0.79
Sometimes
Rarely
Never
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98.485.4Very Often
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NCQA PCMH Standards
1. Access and Communication (9)( )
2. Patient Tracking and Registry Functions(21)
3. Care Management(20)
4. Patient Self‐Management Support(6)
5. Electronic Prescribing(8)
6. Test Tracking(13)
7. Referral Tracking(4)
8 Performance Reporting and Improvement(15)8. Performance Reporting and Improvement(15)
9. Advanced Electronic Communication(4)
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Access and Communication
• Policies addressing patient continuity, access and communication and data to prove implementation
• Open‐access scheduling– Benefits
– New challenges
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Access to Care
How easy is it for you to get care when you need it?
0
0.35Very Difficult
How easy is it for you to get care when you need it?
Pilot Ideal
15.5
0
33.18
2.11
Easy
Difficult
35
84.5
64.35Very Easy
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Open‐Access Scheduling
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Creating Time and Space
L O h d ti• Lower Overhead = more time
• Technology
• Make demand meet supply
• More time to take time to:• More time to take time to:
• Get more done and reduce return visits
• Increase satisfaction
• Improve outcomes through clearly understood care plans
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y p
• Complete planned care items
• Overcome obstacles
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Access to a Physician
Over the past few months how easy has it been for you to talk to a
0.88
2.47Very Difficult
Over the past few months, how easy has it been for you to talk to a doctor?
Pilot Ideal
17.9
1.1
31.09
6.65
Easy
Difficult
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80.5
59.79Very Easy
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Patient Tracking and Registry Functions
• Many of the requirements relate directly to EMR capabilities
• The challenge is in actually using itCapture granular data from diverse sources and load into– Capture granular data from diverse sources and load into the registry.
• The need for one authoritative and flexible system
• Opportunities for outside help
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The Difference Between an EHR and a Registry
El i h l h R i
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• Electronic health record
• Registry
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Patient Tracking and Registry Function
• Health IT opportunities
– Data mining
– Data entry
– Under new Meaningful Use Rule, will the EHR industry deliver on a user friendly interface with powerful registry function?
• Need to easily provide interactive, detailed, and customizable reports to assist in the nitty‐gritty work of real‐world quality improvement
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Care Management
• Team‐based, guideline‐driven outreach– Ironic that “non physician” requirement prevented us from receiving credit for this standard
• Keep the PCP at the center of the teamp
• An opportunity to “outsource” care management– One element explicitly refers to
di i / i i i h “coordination/communication with “case management”/”disease management”
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Care Management
• The Care Manager
– Keep the team on track
– Identify and lead continuous quality improvement effortsimprovement efforts
• Process
• Outcome
• What it would take from a physician perspective?
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Physicians as “Team Players”
• Make time and space
• Pay for it
• Continuity and trust
• Technology available and affordable
• Sine qua non – IHI’s triple aim
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Patient Self‐Management Support
• Scored on % of pts receiving at least 3 activities• Scored on % of pts receiving at least 3 activities from a list of 7 over a 3 month period
• The constraints of time and money
• Health Coaches• Health Coaches
– Credibility and caller ID
– Closing the communication circle
• New communication platforms for sharing of clinical information between coach and PCP
• The Internet
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Self‐Management and Confidence
0
0.67N/A
How confident are you that you can control and manage most of your health problems?
Pilot Ideal
33
2
35.19
2.94
Confident
Not Confident
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65
61.21Very Confident
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Inclusion in Care Plan
Health care can include choices about medicine, surgery or other
4.69.5N/A
Health care can include choices about medicine, surgery or other treatment. In the last 12 months, how often did you feel you were included in decisions about your health care choices (care plan)?
Pilot Ideal
15.9
1
0
11.72
1.19
0.4
Sometimes
Rarely
Never
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78.577.19Very Often
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Electronic Prescribing
• Primarily a technical issue in the realm of EHRs, pharmacy networks, and local pharmacy implementation
• Challenges
– Harder to track than faxed prescriptions in our system.
– Variable capability for controlled substances.
– Reduced flexibility in prescribing due to restrictive drug databases.
– Current and complete listings of pharmacies
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Test Tracking
• Had to create our own system for this
• Comprehensive and Flexible.
• Web‐portals for test providers are common.
• Document‐centric system with routing capability• Document‐centric system with routing capability preferable to a messaging‐centric system that can handle attachments.
• Workflow around result tracking should incorporate capt re of gran lar registr datacapture of granular registry data
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Test Tracking Management System
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Test Tracking ‐ Lab Results
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Lab Result SurveyOver the past few months, how easy has it been for you to get lab
0.5
0.86Very Difficult
p , y y gresults?
Pilot Ideal
28.3
0.5
31.6
2.85
Easy
Difficult
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70.6
64.69Very Easy
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Referral Tracking
• Essentially an extension of Test Tracking
• Provider review of consultations should be h dl d kfl f hhandled as a separate workflow from other EHR messaging (e.g., Rx refills, phone calls, etc.)
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Performance Reporting and Improvement
• Flows from Registry functionality but requires ongoing attention
• Improvement work is easily pushed to the periphery in a busy practice
• There is improvement that comes from having systems in place, but a little i t t f ti d i ldinvestment of time and energy can yield great results
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Performance Reporting and Improvement (cont’d)
• Collaborative opportunities:
– Team leadership
–Quality Improvement coachingQuality Improvement coaching
–Data collection and analysis
–Goal setting
–Who pays for this?–Who pays for this?
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Example of Registry Reports
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Advanced Electronic Communication
• Email• Email
• Practice websites/portals
• Standardized screening tools
• Web‐based educational modules
• Communicate electronically with case/disease managers
• Remote Monitoring
W k d f i b t• Work needs a means of reimbursement
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The Next Steps for the PCMH
• NCQA anticipates revised standards to be released in January 2011
J i C i i l b i di i• Joint Commission plans to begin accrediting “Primary Care Home Option” in July 2011– Intends to be linked to increased reimbursement from third party payers
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“Meaningful Use”
• EHRs are working to meet criteria for both Meaningful Use and PCMH recognition
• Meeting standards risk becoming “cookbook” if notMeeting standards risk becoming cookbook if not modified to require broader demonstration of patient experience and clinical outcome thresholds
• There is more ork to done here for hich pro iders• There is more work to done here, for which providers might seek outside help
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What Do Patients ReallyWant?
• Often more than a service – a Relationship
• Fee‐for‐service is often perceived as patient‐centered care.
i h i h ld ’ b b l• Patient choices shouldn’t become obstacles to a provider’s desire to meet outcomes.
• Patient‐centeredness is a balancing act
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Patient Satisfaction
Would you recommend this practice to your friends and family?
0
1.25N/A
Would you recommend this practice to your friends and family?
Pilot Ideal
0
96 96
1.79No
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100
96.96Yes
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Collaboration Opportunities
• Smaller (and larger) practices will likely require ( g ) p y qsome level of assistance to realize truly patient‐centric care
• PCMH providers who choose capable partners to provide integrated support services and healthprovide integrated support services and health information connectivity will likely fare better than those who opt to build it all themselves
• Any collaborative effort needs to be personal and efficient, and it must demonstrate value for patients and providers
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Many Challenges Lie Ahead…
• Physician skepticism of new primary care modelsy p p y
• Coordination outside of an integrated delivery model
• Questions around program sponsorship
• Adoption of meaningful payment reform and aligned incentives
• Virtual versus onsite care management and practice supportpractice support
• History and perceptions
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Change Isn’t Easy, But It’s Worth It
• Flexible and efficient care delivery models will be needed for PCPs and population health mgmt organizations to work together using shared data and a unified care planshared data and a unified care plan
• The promise of patient centric models of care will be fulfilled only with collaboration acrosswill be fulfilled only with collaboration across the entire medical neighborhood
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