disclosures
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AHRQ and the Medical Home: Building a Blueprint David Meyers, MD Director, AHRQ Center for Primary Care AHRQ Annual Conference September, 2010. Disclosures. The speaker has no financial or other conflicts of interest to report. Disclosures. - PowerPoint PPT PresentationTRANSCRIPT
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AHRQ and the Medical Home:Building a Blueprint
David Meyers, MDDirector, AHRQ Center for Primary Care
AHRQ Annual ConferenceSeptember, 2010
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Disclosures
The speaker has no financial or other conflicts of interest to report
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Disclosures
The speaker has no financial or other conflicts of interest to report
(After all, I’m a bureaucrat)
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Bureaucrat
bu·reau·crat – 1.an official of a bureaucracy. – 2.an official who works by fixed routine
without exercising intelligent judgment. Or in my son’s words…
I go to a lot of meetings and spend my day reading and writing email.
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Session Overview
Introductions and Welcome (5 minutes) An Update on AHRQ’s Activities
in Support of the PCMH (15 min) Perspective: Research Needs (10 min)
– Debbie PeikesSenior Researcher, MPR
Perspective: Implementer Needs (10 min)– Michael Barr
Vice President, ACP Audience Response (40 minutes)
– Where should AHRQ focus future activities in support of the PCMH?
Wrap-up (5 minutes)
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Goals
1. Participants will leave with an understanding of AHRQ’s activities in support of the primary care PCMHa) Participants will see how feedback from their colleagues in
2009 has been incorporated into AHRQ’s activities
2. AHRQ will leave with a fuller understanding of the needs of its stakeholdersa) Researchersb) Implementersc) Policy-makersd) American public
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AHRQ Mission Statement
To improve the quality, safety, efficiency, and effectiveness of health care for all Americans
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What AHRQ does
Generates New Knowledge
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The Medical Home
AHRQ believes that the primary care medical home, also referred to as the patient centered medical home (PCMH), advanced primary care, and the healthcare home, is a promising model for transforming the organization and delivery of primary care.
Synthesizes Evidence
Supports Implementation
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A home for the PCMH
Center for Primary Care, Prevention, and Clinical Partnerships– Primary Care
PBRNs– Health IT– Prevention and Care Management– Mental Health / Primary Care Integration
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Primary Care
AHRQ recognizes that revitalizing
the Nation’s primary care system is foundational to achieving
high-quality, accessible, efficient health care for all Americans.
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The Medical Home
A medical home is not simply a place but a model of primary care that delivers care that is: – Patient-Centered– Comprehensive– Coordinated– Accessible, and– Continuously improved through a
systems-based approach to quality and safety
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The Medical Home
A medical home is not simply a place but a model of primary care that delivers the care that is: – Patient-Centered– Comprehensive– Coordinated– Accessible, and– Continuously improved through a systems-
based approach to quality and safety
AHRQ believes that Health IT, workforce development, and payment reform are critical to achieving the potential of the medical home.
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AHRQ’s Definition of the Medical Home
http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/what_is_pcmh_
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AHRQ and the Joint Principles Closely Aligned
Patient-Centered Comprehensive
– Team-based care
Coordinated Accessible Quality and safety Health IT Workforce development Payment reform
Personal physician Physician directed
practice Whole person
orientation Care Coordination
– Health IT
Quality and safety Enhanced access Payment
AAFP, AAP, ACP, AOA
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AHRQ PCMH Research
Retrospective Evaluations– Health Partners (Minnesota)– WellMed (Texas)
Mixed Methods Evaluations– Transforming Primary Care Practice
14 2-year awards $600K per study Awarded summer 2010
Establishing a Research Agenda– Co-funded with CWMF and ABIMF– Collaboration of SGIM, STFM, APA– Results published June 2010 in JGIM
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Measurement
Developing measures of care coordination in primary care– Care Coordination Measure Atlas
Collaboration of Battelle and Stanford Released this week
– Phase II of measure development 2010-11
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Measurement
Developing measures of care coordination in primary care
Planning for development of measure of ‘team-ness’– Multi-partner collaboration – Kick-off meeting held earlier this month
Measurement– Developing measures of care coordination in primary care– Planning for development of measure of ‘team-ness’– Developing a PCMH version of the Consumer Assessment of
Healthcare Providers and Systems (CAHPS) Expected in 2011
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Synthesis
Foundational White Papers– Necessary but Not Sufficient: The HITECH
Act’s Potential to Build Medical Homes– Engaging Patients and Families in the
Medical Home– Integrating Mental Health into the Medical
Home
– Developed in collaboration with Mathematica Policy Research and National Commission on Quality Assurance
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Synthesis
Foundational White Papers– Necessary but Not Sufficient: The HITECH
Act’s Potential to Build Medical Homes– Engaging Patients and Families in the
Medical Home– Integrating Mental Health into the Medical
Home
– Address Policy and Research Issues
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Necessary but Not Sufficient: The HITECH Act’s Potential to Build Medical Homes
While the meaningful use of Electronic Health Records (EHRs) helps support some aspects of the PCMH model, policy options available in HITECH and in broader health reform legislation could ensure EHRs are implemented in a way that will support primary care transformation.
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Necessary but Not Sufficient: The HITECH Act’s Potential to Build Medical Homes
Policy options include:1. Adding explicit functionalities that directly support
the PCMH model to the recently released EHR certification standards and criteria.
2. Adding meaningful use requirements that support the PCMH model for stages 2 and 3 of the EHR Incentive Program.
3. Funding the provision of technical assistance to primary care practices on PCMH transformation alongside the planned assistance on health IT adoption through Regional Extension Centers (RECs) or through a Primary Care Extension Service.
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Engaging Patients and Families in the Medical Home
How can policymakers ensure that the PCMH is responsive to and reflective of the goals, preferences, and needs of patients?
By promoting the involvement of patients and families in the medical home at three levels: – in their own care, – In practice-level quality improvement, and – In policy and research
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Engaging Patients and Families in the Medical Home
Policy options include:
Requiring patient involvement to qualify a practice as a medical home
Using financial incentives to reward practices for involving patients and families
Supporting practices with technical assistance and tools
Ensuring Health IT is patient-focused Incorporating patient input in the design,
implementation, and evaluation of medical home pilot projects
Conducting additional research
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Integrating Mental Health into the Medical Home
Normalize MH in mainstream medical practice – truly adopt a whole person approach to care.
Integrate reimbursement for the time and resources needed to provide MH treatment in the PCMH.
Develop performance measures to encourage adoption of integration while providing a source for ongoing feedback and improvement opportunities.
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Two Additional Reports
Building Value: The Role of PCMHs and ACOs in Care Coordination
Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care
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Synthesis
Database of published literature on the medical home– Over 500 citations– Searchable by PCMH domain, policy
relevance, and outcomes– Includes a section on foundational
documents and articles
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Implementation
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Synthesis Planned white papers for 2011:
– Analysis of PCMH outcomes– Exploration of PCMH within the larger health care system– With potential for additional topics
Upcoming series of briefs on the status of primary care in the US– Includes new analysis of the primary care workforce
Toolkit on integrating the CCM in safety net setting– Visit: http://www.ahrq.gov/populations/businessstrategies/– Companion toolkit on utilizing practice coaching
Visit: http://www.ahrq.gov/populations/businessstrategies/coachmanl.htm
– Currently conducting field evaluation
National learning collaborative around the use of practice facilitators and practice coaching– Launching fall 2010
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Implementation
Building a PCMH Information Model– Describe the PCMH in terms of the information
flows and interactions between and among patients/consumers and other PCMH stakeholders
– Develop new ‘functional use cases’– Examine current standards and existing ‘technical
use cases’ in relation to the PCMH– Identify gaps
– Contract awarded to Westat– Began Summer 2010
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Opportunities
2010 Affordable Care Act:– Section 3502: Establishing community
health teams to support the patient-centered medical home
– Section 5405: Primary Care Extension Program
Both sections authorized without the appropriation of funds
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Putting it All Together
Research Measurement Evidence Synthesis Evidence-informed Policy Options Implementation
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Dissemination
PCMH.AHRQ.Gov
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PCMH.AHRQ.Gov
Targeted towards meeting the needs of Policy Makers and Researchers
Includes:– AHRQ definition of the medical home– Searchable article database– Foundational white papers
Health IT Patient and Family Engagement Mental Health Integration And additional reports
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PCMH.AHRQ.Gov
Targeted towards meeting the needs of Policy Makers and Researchers
Includes:– AHRQ definition of the medical home– Searchable article database– Foundational white papers
Will continue to grow and expand
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PCMH.AHRQ.Gov
Targeted towards meeting the needs of Policy Makers and Researchers
Includes:– AHRQ definition of the medical home– Searchable article database– Foundational white papers
Will continue to grow and expand
Please visit and help us spread the word
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Federal Collaboration
AHRQ heard from federal partners as well as external stakeholders the need to coordinate federal activities around the PCMH and primary care
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Federal Collaboration
AHRQ heard from federal partners as well as external stakeholders the need to coordinate federal activities around the PCMH and primary care
In response, AHRQ convened a Federal Collaborative on the PCMH– Share information so that participants have
a common understanding of PCMH– Foster collaborations and share expertise
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Thank You
One minute for clarifying questions… Research Needs and the Needs of
Researchers
– Remarks from Debbie Peikes, Ph.D. Senior Researcher at Mathematica Policy
Research Visiting Lecturer at Princeton University
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The Patient-Centered Medical Home: Research Needs and the Needs of Researchers
September 27, 2010
AHRQ Annual Conference
Bethesda, MD
Debbie Peikes, Ph.D.
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We Need Good Evaluations
Payers/insurers: Will the PCMH reduce costs enough to cover the payments to providers and in-kind supports?
Practices: Transformation requires staffing, IT changes, time, and $. Will these translate into more satisfaction, $?
Patients: Will experience and outcomes improve? Will premiums fall?
Vendors: Will this movement exist in 5 years?
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The PCMH Model is Promising. . . but Risky
Risks:
Model isn’t actually implemented fully
Model is implemented, but does not work– Increases costs– Decreases satisfaction of patients– Decreases provider satisfaction– Decreases quality
Simply proceeding without evidence may divert resources from other primary care transformations that would work
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What Can an Evaluation Deliver?
Document whether the PCMH model was implemented
Identify barriers and facilitators to being a medical home
Assess effectiveness to justify investment
Measure performance to reward providers differentially
Guide replication of successful features
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How Do Practices Evolve into Medical Homes?
Efforts needed to reach MH criteria (time, internal and external resources, $)
Limits, potential of health IT
Ease of changing staffing and workflows
Resources required from outside the practice
Best practices and models– For patient outreach, recruitment, and
engagement– For coordination– For chronic care, etc.
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What Is the Impact of the PCMH? Disease-specific and population-based quality of care
measures– Process: Evidence-based care (e.g., foot exams
for patients with diabetes)– Outcomes: Ambulatory-care sensitive
complications– Coordination of care (harder to measure)– Patient experience
Provider experience– If providers are worse off, they won’t want to do this
Service use and cost– If this isn’t cost neutral or cheaper, payers won’t
play
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Current Research Evidence is Weak
Well designed studies are not testing the full medical home (e.g., Guided Care, GRACE), or do so in a closed system (Group Health), or don’t have access to cost data (NDP)
Many studies are poorly designed, or do not report methods (e.g., North Carolina)
Many planned studies are too short, have not represented the counterfactual, do not address clustering, and are underpowered
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Research Needs-2
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Research Needs1. Standardized measures of different medical home models to test variants
2. Fair comparison groups-similar before the intervention At the practice level At the patient level Consider random assignment, staggered rollouts
3. Information on best claims-based approaches to attribute patients to their practices
4. Adequate follow-up Need time to allow transformation to happen Most evaluations are using only 1.5–2 years
5. Statistical techniques that account for clustering at the practice level Not doing so will give false positives
6. Large sample sizes We may erroneously find no effect because practices don’t have enough time to change or there
isn’t enough sample to detect change Costs vary so much it is difficult to separate intervention effects from random noise (this affects
P4P too!)
7. Data repositories and guidelines for cross-walking all payer claims data
8. Well defined intermediate and final outcome measures that are comparable across studies
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Feedback from the Front Lines
Remarks from Michael Barr
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Feedback from the Front Lines
AHRQ Annual MeetingSeptember 2010
Michael S. Barr, MD, MBA, FACPSenior Vice President
Division of Medical Practice, Professionalism & Quality202-261-4531
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Disclosure of Conflicts of Interest:
Grant funding from Pfizer and UnitedHealthGroup to support program development (ACP Medical Home Builder)
Quality improvement programs sponsored by pharmaceutical companies as part of ACPNet & ACP Closing the Gap
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"I put a dollar in a change machine. Nothing changed." — George Carlin
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Anecdotal Reactions
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Some
What ^ Physicians Hear…Patient-Centered Medical Home
Health Care HomePerson-Centered Health Care Home
Meaningful UseCertified EHR Technology
Complete EHRsEHR Modules
Accountable Care Act (PPACA, ACA)Maintenance of Certification
Physician Quality Reporting Initiative – PQRIHITECK
E-prescribing Incentive Program
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Drawing by: M.C. Escher
What ^ Physicians See…Some
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What ^ Physicians Say…• Honestly, I have given up on all my professional organizations -
they simply cannot or will not understand the point of view of the solo practitioner.
• Haven't we given up enough of our autonomy? Aren't enough non-physicians in control of our destiny as it is?
• I agree that there are a lot of issues in medicine today (billing, paperwork, bureaucracy to name only a few). However, if those issues render you cold and uncaring, my friend, I strongly suggest you find another profession.
• …the complex requirements of "meaningful use" mainly serve the EHR companies (who, not surprisingly, had a hand in developing the rule).
Some
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How ^ Physicians Feel…Some
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Physicians Need…
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Listening Session
We invite members of the audience to share their observations and recommendations with AHRQ– Our primary goal is to learn from you what
you see as the role for AHRQ moving forward