The Patient-Centered Medical Home

1. The Patient-Centered Medical Home Sarat Raman, MD Dept. of Family & Community Medicine Tulane University School of Medicine

2. Objectives • By the end of this session the learner will be able to: • Discuss the need for change in the healthcare system of the US. • Describe the seven principles of the patient-centered medical home • Describe some of the proven benefits of the patient-centered medical home • Discuss the variety of locations, collaborative partners, clinic types and health care settings that have successfully used the patient centered medical home

3. IHI “Triple Aim” • “Work to improve site-specific care for individuals should expand and thrive. In our view, however, the United States will not achieve high-value health care unless improvement initiatives pursue a broader system of linked goals. In the aggregate, we call those goals the “Triple Aim”: • improving the individual experience of care; [better care] • improving the health of populations; [better health] • and reducing the per capita costs of care for populations. [lower cost] “ Donald M. Berwick, Thomas W. Nolan and John Whittington The Triple Aim: Care, Health, And Cost.Health Affairs, 27, no.3 (2008):759-769

4. Better health Ranking Country • 1 France • 2 Italy • 3 San Marino • 4   Andorra • 5   Malta • 6 Singapore • 7 Spain • 8Oman • 9 Austria • 10 Japan • 36 Costa Rica • 37 United States • 38 Slovenia • 39 Cuba The World Health Report 2000 – Health systems: Improving performance

5. Better Health • Of 13 [industrialized] countries in a recent comparison,the United States ranks an average of 12th (second from the bottom) for 16 available health indicators • 13th (last) for low-birth-weight percentages • 13th for neonatal mortality and infant mortality overall • 11th for postneonatal mortality • 13th for years of potential life lost (excluding external causes) • 11th for life expectancy at 1 year for females, 12th for males • 10th for life expectancy at 15 years for females, 12th for males • 10th for life expectancy at 40 years for females, 9th for males • 7th for life expectancy at 65 years for females, 7th for males • 3rd for life expectancy at 80 years for females, 3rd for males • 10th for age-adjusted mortality Starfield B. Is US Health Really the Best in the World?. JAMA. 2000;284(4):483-485.

6. Tragedy in the Skies What if it happened every other day? • 23,400 * 3.5 = ??? • = 81,900 deaths per year… # of passengers in a 747 450 Weeks in a year 52 Total 23,400

7. Better health • “At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS. To Err is Human: Building a Safer Health System, Institute of Medicine. Sept 1999.

8. Danger Will Robinson! Danger! • US estimates of the combined effect of errors and adverse effects that occur because of iatrogenic damage not associated with recognizable error include: • 12,000 deaths/year from unnecessary surgery • 7000 deaths/year from medication errors in hospitals • 20,000 deaths/year from other errors in hospitals • 80,000 deaths/year from nosocomial infections in hospitals • 106,000 deaths/year from nonerror, adverse effects of medications • These total to 225,000 deaths per year from iatrogenic causes. StarfieldB. Is US Health Really the Best in the World?. JAMA. 2000;284(4):483-485.

9. Better Care

10. Better Care

11. Better Care Consumer Assessment of Healthcare Providers and Systems (CAHPS) program: 2012 Clinician & Group Survey Results

12. Lower Costs Ranking Country Expenditure Per Capita • 1 France 4 • 2 Italy 11 • 3 San Marino 21 • 4   Andorra 23 • 5   Malta 37 • 6 Singapore 37 • 7 Spain 24 • 8 Oman 62 • 9   Austria 6 • 10 Japan 13 • 36 Costa Rica 50 • 37 United States 1 • 38 Slovenia 29 • 39 Cuba 118 The World Health Report 2000 – Health systems: Improving performance

13. Lower costs Major components of the $3.5 trillion spent in fiscal 2010 http://www.factcheck.org/2011/07/fiscal-factcheck/

14. Lower costs http://www.marketwatch.com/health-care/reform/snapshot

15. Lower Costs K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007

16. The Patient-Centered Medical Home • The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx

17. Why Outpatient? A typical month of health care in the United States N England Journal of Medicine 2001;344:2021-25]:

18. History of the PCMH • 1967 – AAP introduces the term “medical home”, which described a single source of medical information about a patient • 1978 - WHO made the Alma Ata declaration describing the importance of primary care. This also laid some of the basic tenets in language that is now used to describe the PCMH • 1990’s – IOM begins mentioning the “medical home” • 2002 – The Future of Family Medicine Collaborative –“every American should have a Personal Medical Home that servesas the focal point through which all individuals— regardless of age, sex, race, or socioeconomic status—receive their acute, chronic, and preventive medical care services.” – recognizing the importance of the Chronic Care Model as a contributor to the PCMH • 2006 – ACP developed “advanced medical home” • 2006 – IBM and Patient Centered Primary Care Collaborative to promote the medical home concept

19. History of the PCMH • 2007 – Release of the Joint Principles of the Patient-Centered Medical Home. • American Academy of Family Physicians • American Academy of Pediatrics • American College of Physicians • American Osteopathic Association • Representing 333,000 physicians. http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

20. Health Care Endorsements • American Academy of Hospice and Palliative Medicine • American Academy of Neurology • American College of Cardiology • American College of Chest Physicians • American College of Occupational and Environmental Medicine  • American College of Osteopathic Family Physicians • American College of Osteopathic Internists • American Geriatrics Society • American Medical Association • American Medical Directors Association • American Society of Addiction Medicine • American Society of Clinical Oncology • Association of Professors of Medicine • Association of Program Directors in Internal Medicine • Clerkship Directors in Internal Medicine • Infectious Diseases Society of America • Society for Adolescent Medicine • Society of Critical Care Medicine http://www.pcpcc.net/content/specialist-health-endorsements

21. Joint Principles of the Patient-Centered Medical Home • Personal Physician • Physician Directed Medical Practice • Whole Person Orientation • Care is Coordinated and/or Integrated • Quality and Safety • Enhanced Access • Payment http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

22. Joint Principles of the Patient-Centered Medical Home • Personal physician • Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

23. Joint Principles of the Patient-Centered Medical Home • 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. http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

24. Joint Principles of the Patient-Centered Medical Home • Whole person orientation • The personal physician is responsible for providing for all the patient’s 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. http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

25. Joint Principles of the Patient-Centered Medical Home • Care is coordinatedand/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

26. Joint Principles of the Patient-Centered Medical Home • Quality and safetyare hallmarks of the medical home: • Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family. • Evidence-based medicine and clinical decision-support tools guide decision making • Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement. • Patients actively participate in decision-making andfeedback is sought to ensure patients’ expectations are being met • Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication • Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model. • Patients and families participate in quality improvement activities at the practice level. http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

27. Joint Principles of the Patient-Centered Medical Home • Enhanced accessto care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff. http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

28. Joint Principles of the Patient-Centered Medical Home • Paymentappropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework: • It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit. • It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources. • It should support adoption and use of health information technology for quality improvement; • It should support provision of enhanced communication access such as secure e-mail and telephone consultation; • It should recognize the value of physician work associated with remote monitoring of clinical data using technology. • It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits). • It should recognize case mix differences in the patient population being treated within the practice. • It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting. • It should allow for additional payments for achieving measurable and continuous quality improvements. http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

29. IHI “Triple Aim” • “Work to improve site-specific care for individuals should expand and thrive. In our view, however, the United States will not achieve high-value health care unless improvement initiatives pursue a broader system of linked goals. In the aggregate, we call those goals the “Triple Aim”: • improving the individual experience of care; [better care] • improving the health of populations; [better health] • and reducing the per capita costs of care for populations. [lower cost] “ Donald M. Berwick, Thomas W. Nolan and John Whittington The Triple Aim: Care, Health, And Cost.Health Affairs, 27, no.3 (2008):759-769

30. PCMH Outcomes • Better Health • 2010 study showed improvement in condition-specific outcomes (measures of the quality of care from the Ambulatory Care Quality Alliance (ACQA) Starter Set), measures of delivery of clinical preventive services and chronic disease care. • ACQA scores improved 8.3%-9.1% • Chronic Care Scores improved 5.0%-5.2% • Improved Prevention Scores (although not statistically significant) Jaén, C., Ferrer, R. et al., Patient Outcomes at 26 Months in the Patient-Centered Medical Home National Demonstration Project. Ann Fam Med 2010;8(Suppl 1):s57-s67.

31. PCMH Outcomes • Better Health • Air Force: 77% of diabetic patients improved glycemic control • MN: Health Partners: 129% increase in optimal diabetes care; 48% in heart disease care • NJ: BCBS of NJ: 8% improvement in HgbA1c • NC: Community Care of North Carolina: 21% increase in asthma staging; 112% increase in influenza inoculations Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.

32. PCMH Outcomes • Better Health • OH: Humana Queen City Physicians: 22% decrease in uncontrolled HTN • OR: CareOregon Medicaid and Dual Eligibles: 65% with controlled A1c vs 45% pre-PCMH • PA: Geisinger Health System Proven-Health Navigator PCMH Model: improved quality: 74% preventive Care, 22% Coronary Artery Care; 34.5 % Diabetes Care Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.

33. PCMH Outcomes • Better Health • PA: Independence Blue Cross – Pennsylvania Chronic Care Initiative: in Diabetics: 49& improvement in A1c; 25% increase in BP control; 27% increase in cholesterol control • TX:WellMed, Inc: LDL control from 51%to 95% in heart disease patients; mammography from 19%to 40%; colon cancer screening from 11%to 50% Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.

34. PCMH Outcomes • Better Care • 2010 study showed no improvement in patient related outcomes including ratings of the 4 pillars of primary care (easy access to first-contact care, comprehensive care, coordination of care, and personal relationship over time), global practice experience, patient empowerment, and self-rated health status. Jaén, C., Ferrer, R. et al., Patient Outcomes at 26 Months in the Patient-Centered Medical Home National Demonstration Project. Ann Fam Med 2010;8(Suppl 1):s57-s67.

35. PCMH Outcomes • Better Care • CO: Colorado Medicaid and SCHIP: Increased well-care visits 54%->73% • FL: Capital Health Plan: 250% increase in primary care visits • MA: Pediatric Alliance for Coordinated Care: 60.9% reported increased ease to communicate with MD, 61.4% reported it was easier to get early medical care • MI: BCBS of Michigan: 60% better access to care (25% in non-participating sites) Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.

36. PCMH Outcomes • Better Care • MN: Healthpartners: reduced appointment wait time by 350% (26 days to 1 day) • ND: BCBS of North Dakota-MediQHome Quality Program: 24% reduction in ED visits, 30%reduction in ED visits in chronic disease patients • NY: Capital District Physicians’ Health Plan: 24% lower hospital admissions • OK: Oklahoma Medicaid: 8% increase in “always getting treatment quickly” • PA: PinnacleHealth: 0% 30-day readmission rate vs 10-20% for non-PCMH Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.

37. PCMH Outcomes • Better Care • Veterans Health Administration and VA Midwest Healthcare Network: 8% reduction urgent care visits, 4% reduction in acute admission rates, 27% reduction in admissions for chronic disease patients • WA: Regence Blue Shield (Intensive Outpatient Care Program with Boeing) 2012: 65% reduced patient reported missed workdays • WA: Group Health of Washington: 83% of patient calls resolved on first (vs. 0% pre-PCMH) Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.

38. PCMH Outcomes • Lower Costs • CA: BCBS of California ACO Pilot: %15.5 million overall health care cost savings • CO: Colorado Medicaid and SCHIP: $215 lower PMPY • Idaho: BCBS of Idaho Health Service: $1 million reduction in single year claims • MD: CareFirst BCBS: 4.2% reduction in expected health care costs for patients in 60% of practices participating for 6+ months.; $40 million savings in 2011. Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.

39. PCMH Outcomes • Lower Costs • NC: Community Care of North Carolina: $1.145 billion savings between 2006-2010; 11% lower pharmacy costs • OR: CareOregon Medicaid and Dual Eligibles: 9% lower PMPM costs • SC: BCBS of South Carolina: 6.5% lower total PMPM medical and pharmacy costs • TX: BCBS of Texas: $1.2 million health care costs savings Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.

40. PCMH Outcomes • Provider Satisfaction • WA: Group Health of Washington: Less emotional exhaustion (10% vs 30% in control group) Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.

41. Objectives • By the end of this session the learner will be able to: • Discuss the need for change in the healthcare system of the US. • Describe the seven principles of the patient-centered medical home • Describe some of the proven benefits of the patient-centered medical home • Discuss the variety of locations, collaborative partners, clinic types and health care settings that have successfully used the patient centered medical home

42. Bibliography • Donald M. Berwick, Thomas W. Nolan and John Whittington The Triple Aim: Care, Health, And Cost. Health Affairs, 27, no.3 (2008):759-769 • The World Health Report 2000 – Health systems: Improving performance • Starfield B. Is US Health Really the Best in the World?. JAMA. 2000;284(4):483-485. • To Err is Human: Building a Safer Health System, Institute of Medicine. Sept 1999. • Consumer Assessment of Healthcare Providers and Systems (CAHPS) program: 2012 Clinician & Group Survey Results • http://www.factcheck.org/2011/07/fiscal-factcheck/ • http://www.marketwatch.com/health-care/reform/snapshot • K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum. Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007 • http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx • N England Journal of Medicine 2001;344:2021-25]:

43. Bibliography • http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home • http://www.pcpcc.net/content/specialist-health-endorsements • Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012. • The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change. Robert Graham Center for Policy Studies in Family Medicine and Primary Care. November 2007. • Starfield, B., Shi, L., and Macinko, J., Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly, Vol. 83, No. 3, 2005 (pp.457-502). • Jaén, C., Ferrer, R. et al., Patient Outcomes at 26 Months in the Patient-Centered Medical Home National Demonstration Project. Ann Fam Med 2010;8(Suppl 1):s57-s67.

44. Questions? The slides from this presentation and some of the source material are available at the Tulane Department of Family and Community Medicine. http://tulane.edu/som/departments/fammed/seminars.cfm