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M24: Enhancing Primary Care Value in Managing

Care

Faculty Team:

Brenda Reiss-Brennan

Karen Boudreau

These presenters have

Nothing to disclose

Mini Course IHI National Quality Forum

Course Objectives:

1) To create a set of values and outcomes that make the most difference in the lives of individuals and communities

2) To build a framework for enhancing the quality of primary care through designing relational networks

3) To define how to measure whether a health system delivers on these values and desired outcomes

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Agenda: Enhancing Primary Care Value at an Affordable Cost to the Community

I. Introduction & Value Stories

a. Social Context of Healthy Communities

b. Value Exercise: What matters most?

c. Social Context Community Value Examples: Intermountain MHI and IHI Triple Aim Sustainable Lessons

d. Consensus Principles: Value Consumer & Family Defined

II. “We build it, We will come” : Health Center Social Network Design Experience

a. Monitoring value “gaps”: Reciprocity Science & Quality Banks

b. Health Center Site Visits & Value Measures Presentations

III. Occupy Health through our Neighborhoods

a. How do we make this happen?

b. What exchanges do we need to empower social responsibility and community stewardship?

Americans Don’t Feel As Healthy As We Used To

DDB Needham Life Style survey archive, 1975-1999. Putnam, R. Bowling Alone,2000

Is this necessarily the result of declining social capital ?

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In 2009 Doctors Wrote More Psychiatric Scripts Than There Were People in this Country

Good Life Style. May 11, 2010.

Rise of Chronic Disease

Milken Institute Chronic Disease Index

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Multiple Conditions Increase Complexity

Milken Institute Chronic Disease Index

Mrs. WatsonProblem List:

• Diabetes• Hypertension• Mild congestive heart failure• Arthritis• MCI

Reasons for visit (with her husband): Hip and knee pain, no energy,

questions about medicines, dizziness, low blood sugar and a

recent fall.

The rest of the story:

Not leaving houseNot sleeping

CrankyHusband exhausted

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In 2009 doctors wrote more psychiatric scripts than there were people in this country

Good Life Style. May 11, 2010.

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Declining Perceptions of Honesty and Morality, 1952-1998

Putnam, R. Bowling Alone, 2000, pg 139. Ben Gaffin and Associates 1965-1976, Washington Post Gallop Survey, 1998.

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TV Watchers Don’t Keep in TouchDDB Needham Life Style survey archive, 1975-1999. Putnam, R. Bowling Alone,2000

Americans Don’t Feel As Healthy As We Used ToDDB Needham Life Style survey archive, 1975-1999. Putnam, R. Bowling Alone,2000

Is this necessarily the result of declining social capital ?

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Is there NO Magic Pill ?

Milken Institute, 2010

Whose Morale Obligation is it to care about the quality of our life, our resources?

Do these chronic diseases have a message for us?

“The body communicates to the world and the world becomes expressed through the body. The body feels and expresses social problems”

(M Merleau-Ponty 1963; A Kleinman, 1985)

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Social Capital in America

Connections within and between social networks

Value of social relations

Role of cooperation and confidence to

attain collective economic results

Health Is Better in High-Social-Capital States

Kawachi, I. et al (1997). “Social Capital, Income Inequality and Mortality” American JOUrnal of public Health 87: 1997, 1491-1495. Putnam, R. Bowling Alone, 2000

“As a rule of thumb, if you belong to no

groups but decide to join one, you cut your risk of dying over the next year in half. If

you smoke and belong to no groups, it’s a toss-up statistically whether you should

stop smoking or start joining..its easier to join a group than to

loose weight, exercise regularly or quit

smoking (pg 331).

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Social Capital and Tolerance Go TogetherGeneral Social Survey archive, 1974-1998. Putnam, R. Bowling Alone,2000

Social Capital and Economic Equality Go TogetherKawachi, I. et al (1997). “Social Capital, Income Inequality and Mortality” American Journal of public Health 87: 1997, 1491-1495. Putnam, R. Bowling Alone, 2000

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Having a good life?Brim OG, C.D. Ryff, and R.C. Kessler, Editors. (2004) How Healthy are We?: A National Study of Well-Being at

Midlife, University of Chicago Press: Chicago.

“Adult Americans rate the development of

relationships with others as the most

important factor in having a good life,

followed by health, then family.”

The Mobile Phone has become the new garden fence: The Joy of Texting

Social Grooming relieves Stress & Boosts Immune System

Dunbar, R. (1996) Grooming, Gossip and the Evolution of Language . Faber and Faber.

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A Blue Zone is a region of the world where people commonly live active lives past the age of 100 years. Scientists and demographers have classified these longevity hot-spots by having common healthy traits and life practices that result in higher-than-normal longevity. The name Blue Zone seems to have been first employed in a scientific article by a team of demographers working on centenarians in Sardinia in 2004. Buettner, D. 2010. The Blue Zone: Lessons for Living Longer. National Geographic Society.

The Value of Social Context

Long Enduring CPR Institutions

Careful assessment of the condition of resources & boundary definition

Method of allocating resources: Collective choice

Reciprocal monitoring results and relationships

Local participants have say in modifying methods, sanctions and incentives

Governing the Commons: The Evolution of

Institutions for Collective Action

Elinor Ostrom, 2009 Nobel

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Relationships Have a Cost

Transaction Costs: (North, D. 1999. Institutions, Institutional Change & Economic Performance. Cambridge University Press)

Knowledge transfer local values and norms

Incomplete information

Limited mental capacity

Measuring the value of the exchange

Enforcing agreements

Performance of economies over time

Today a “good doctor”

Emotionally intelligent

Team player

Obtain information from colleagues and technology

Embrace quality improvement

Use guidelines with compassion

Swensen, et al . 2011 NEJM

“The Revolution in Health Care Delivery”

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Quality and Safety + Healing for Life =Relational Health & Relational Economics

Do No Harm

Listen to the Patient

Include the Family

Manage the Process

Nurture your Teams

Reduce Costs & Waste

Community Stewardship

“Obstacles can boost flexibility and performance” WSJ November 26, 2011 Chains That Set us Free.

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Is Exchange the Key to delivering Value

for the Consumer ?

Created by the combined efforts of providers and staff over the full cycle of care

Any one intervention depends on the effectiveness of the other intervention (Porter, 2010 NEJM)

Effective and fulfilling relationships are the key to efficiency and happiness (aka) quality of life

Who will measure what matters most?

Valuing Our Voices

“When you are caring for your physical and mental health, what do we need to know that matters most to you and your family? .....What do we need to understand? “

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The Quality and Cost Impact of Intermountain’Mental Health Integration (MHI)

• To share our implementation science journey

• To describe Intermountains’ clinical integration high value delivery structure: Primary Care Clinical Program (PCCP)

• To demonstrate results of Mental Health Integration (MHI) team intervention impact on the quality, experience, and cost of chronic disease

Intermountain’ s High PerformanceHealth and Cost Comparison by State

Source: Healthiness – United Health Foundation; Total Health Cost – Kaiser Family Foundation

Worst Health Best HealthMost

Affordable

LeastAffordable

Utah

MAMN

VT

ND

LA

TN

SC

MSAR

HI

NH

GA

CT

WI

ME

RI

SD

NJNE

IA

CO

ID

OR

VA

CA

AZWY

TXOK

NM

NC

NV

AL

WV

FLKY

MO

DE

NYAK

PA

OH

MD

IN

IL

MI

MT

WA

KA

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Intermountain’ s Strategy:Clinical Integration

Focus on the Six Dimensions of Extraordinary Care:

• Clinical Excellence

• Operational Excellence

• Service Excellence

• Physician Engagement

• Employee Engagement

• Community Stewardship

“…high-quality care at costs below average.”

Barack Obama

“Getting to the root of the problem”

Four Habits of High-Value Health Care Organizations

Bohmer, R. NEJM, December, 2011

Specification and Planning

Infrastructure Design

Measurement and Oversight

Self-Study

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Make it easy to do it right:

• Standard line of clinical thought (CPM)

• Be willing to function in a group

• Align clinical data to work process

• Reduce variation & waste

Facilitating, encouraging, supporting patient/family self management (MHI)

Build sustainable community relationships (MHI)

Clinical Program Organizational Culture

Integration & Co-Production Integration Defined

To form, coordinate, or blend into

a functioning or organized whole: Unite

Functioning in a group with standard clinical line of thought (CPM)

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Intermountain Medical Group

Diverse group of clinics and services

•152 primary and secondary care clinic sites

•32 urgent care locations

•9 occupational health locations

•2 on-site employer clinics

•5 community/school clinics

•17 retail pharmacies

4633 employees

•913 physicians

•211 advance practice clinicians

Clinical Integration: Management of Complex Chronic Disease Primary Care Clinical Program

2/3 – cared for routinely in primary care 1/6 1/6

Diabetes, Asthma, Heart Disease, Depression, Obesity, Chronic Pain, SA, etc.

Patient & Family, PCP, and Care Manager (CM) as needed

PCP, CM +mental health

as needed

PCP with MHI Specialist

Consult

*Primary Care Physician (PCP) includes: General Internist, Family Practitioner, Pediatrician

Mental Health Integration Infrastructure

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Healing for LifeHealth Care is Delivered Through

Relationships

Brent James, 2011

What is Mental Health Integration clinical program at Intermountain?

A standardized clinical and operational

team relational process that

incorporates mental health as a

complementary component of

wellness & healing for life

* Mental Health includes Substance Abuse Recovery

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What is Mental Health Integration ?Enhancing Primary Care Value

Sustaining Outcomes

To support Primary Care Providers and MHI Team members with best practices in an effort to:

• Reach as many families as possible

• Improve quality of life

• Increase satisfaction

• Reduce practice burden

• Decrease costs to the system

• Engage community resources

Primary Care ClinicSecondary Care Clinic

Hospital Campus Clinic Multispecialty Clinic

Clinical

Quality

Patient Experience Cost of Care

RNC, Care Manager OD, AOD, Clinic Manager

Medical Directors

Primary Care Clinical Program

The Triple Aim and Shared Accountability

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0

10

20

30

40

50

60

70

80

90

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Routine

Adoption

Planning

79 clinics461,550 patients79 clinics461,550 patients

1 clinic26,265 patients1 clinic26,265 patients

MHI Team Growth 1998-2011

* Includes 6 community based school clinics low income

Mental Health Integration

5 Key Components

Primary Care Clinical Program

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I. Leadership & Cultural Integration

Quality Investment

Local Champions

Practice Teams

Accountability

Co-production

• Train all

• Treat all

• Connect all

Care Manager

Health Advocates

Psychiatrist or Psychiatric NP

Therapist (Psychologist, LCSW, EAP)

Peer Mentor

Community Resources:

CHADD

NAMI

Community Therapists

Physical Therapists

Nutritionist

Pharmacists

Clinic Staff:RN, MA, Reception, Billing

Personalized Primary Care

Our Patients and their Families

Information Technology / EMR / Data / TelehealthClinic Manager

II. Work Flow: MHI Team Roles

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ROUTINE CAREMild Complexity

PCP and Care ManagerResponsive

Family SupportGS=1-3

COLLABORATIVE MHI TEAM

Moderate ComplexityComplex Co-morbidities

Family Isolated or ChaoticGS=4-5

MENTAL HEALTH TEAMHigh Complexity

Psychiatric Co-morbiditiesFamily Support Variable

High Social Burden Danger Risk

GS=6-7

Case IdentificationShared Decision Making

MHI Packets

II. Work Flow: MHI Treatment Cascade

“Isolated”Disconnected/Avoidant

“Burnt out”Confused/Chaotic

“Available in use”

Balanced/Secure

Family Engagement Patterns“Who do you most commonly go to or talk to when you are

distressed or don’t feel well?”

Can we understand our patients better if we know where they

are coming from?

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Your Risk Data

Your Current Status

Your Diagnosis

Your Team Treatment Choices

II. Patient and Family Care Planning Worksheet

III. Information System Integration to support monitoring clinical improvement communication, and operation needs

Information for population based quality

improvement

Financing and clinicoperation needs

Information Systems

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•

Clinical Decision Use of EMR

Team feedback and reporting Registry (EDW) – 1999 to 2011

Depression registry n = 339,413 (1999 – 2011)

120,000 currently active (in the last 12 months)

71,571 unique patients with PHQ9 and 50,335 patients with PHQ2

148,005 PHQ9 and 91,689 PHQ2 (~ 2 PHQ9 or 2 by patient)

70% female

46% private insurance (in 2011)

III. Flow of Information

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IV. Operations & Financing IntegrationValue Incentives and Sanctions

• Achieve a sustainable MHI program all regions

• Saving to System ( ACO,SAO, Community)

• Value Foundation for ‘Medical/Health Home’

• Routinized MHI sites establish-baseline best practice

• TEAM FTE

• Identify operational barriers and plan operational resources for 2013-2014 budgets

• Disseminate evidence to communities

.74 1.0 .27 .73 .78 .70 .14Team FTE

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Vary by location and system

• NAMI

• CHADD

• Local clinicians

• EAP

Important partners and trained patient advocates

Family support

Consumers as leaders and developers of high value care

V. Community Resource Integration

16

13

10

85

4

3

V. National Communities Diffusing MHICommon Set of Value Measures (2012)

3

HVH

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Key Components Beginning Score Current Score

Patient Outcomes 3 6

1.Leadership and Culture 7 15

2.Workflow Integration 8 17

3.Information Systems 4 9

4.Finance/Cost of Care 1 4

5.Community Resource 0 1

Total 23 52

Implementation Scorecard:MHI at Salt Lake Clinic

Planning

Score: 25

Adoption

Score: 50

Routine

Score: 75

Scoring

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Value: Impact on Chronic Disease

• Patient experience

• Clinician experience

• Cost outcomes

• Quality outcomes

Value : Outcomes that matter to patients & the cost to achieve them

High Valued Care = Quality ResultsImpact on building value for results vs. volumes

Urban

Rural

Uninsured School Based

Primary Care Clinics by Stage of MHI Implementation

Rogers, E. Diffusion of Innovations, 1995—discussion of stages

Intermountain Clinics

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Patient Satisfaction

Physician Satisfaction

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Savings to the Insurance Plan For Service Lines Directly Affected by MHI

$406Savings

Quality Measures

54 % Decrease ER Utilization

$667Savings

Remaining service lines includes:Inpatient Services: Obstetrical and Surgical;

Outpatient Services: Urgent care, Specialty care;

Ancillary Services: Pharmacy for other drugs, Lab, Outpatient Radiology and Testing,

Outpatient other, Chemo and radiotherapy, and Other miscellaneous.

Savings to Commercial Insurance

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Change in PHQ-9 Score of ≥5 Points frombaseline to 3 Months (2012)

Initial Score

Patients with

follow up

Increase of

>=5 points

Change of

<=4 points

Decrease of

>=5 points

20-27 points 2,278 19 644 1,615*

15-19 points 2,524 107 774 1,643*

10-14 points 2,111 172 910 1,029*

Initial Score

Patients with

follow up

Increase of

>=5 points

Change of

<=4 points

Decrease of

>=5 points

20-27 points 31.0% 0.8% 28.3% 70.9%

15-19 points 28.9% 4.2% 30.7% 65.1%

10-14 points 23.8% 8.1% 43.1% 48.7%

* Difference between significant improvement and no significant change is <=0.001

Distribution of patients treated at MHI and non-MHI clinicsBy diabetes control and comorbidity

Patient who have depression have their diabetes in better control when treated at an MHI clinic (p < 0.01)

47.50% 45.90%

6.60%

53.10%

42.60%

4.30%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Good Control Moderate Control Poor Control

For patients with diabetes and depression and with 4 or less

comorbidities

NON-MHI CLINICS (N = 442) MHI CLINICS (N = 698)

53.00%

42.50%

4.50%

58.70%

37.60%

3.70%

-10.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Good Control Moderate Control Poor Control

For patients with diabetes and depression and with 5 or more

comorbidities

NON-MHI CLINIC (N = 448) MHI CLINIC (N = 745)

P < 0.01 P < 0.01

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Patients with diabetes and depression (5 or more comorbidity)

Hospitalization and ER from 2006 to 2011

Place of treatment / Phq9 control N

Avg. # Visits for those with

ER

Inpatient Visits for those with Admissions

LOS for those with admissions Significance

MHI clinic 745 3.62 * 2.34 10.14 * P < .05

Non-MHI clinic 448 3.98 2.26 10.37

MHI clinic and Phq9 decrease by 5 pts (sustained) 129 2.41 ** 1.96 * 9.23 *

* P < 0.05** P < 0.01

These are preliminary results not to be published

Adherence to diabetes bundle

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The Quality Challenge

Transitioning From Volumes to Value

The RightCare

For The Right Person

At TheRight Time

The Value Challenge

What Is Value?

Defined around patient experience

Costmeasured

Outcomes achieved