Community Journey Patient Centered Medical Home

1. Community Journey Patient Centered Medical Home Mary Ellen Benzik, MD September 17,2009

2. A Community Collaboration to Improve Chronic Illness Care Calhoun County Pathways to Health

3. Journey of Pathways toHealth Initiative • January 2006 - Integrated Health Partners (IHP), a joint venture physician hospital organization of Battle Creek Health System and Calhoun County Physicians Organization Inc., began chronic disease initiative with Blue Cross Blue Shield of Michigan (BCBSM) • March 2006 - IHP executive leadership studied the Wagner Chronic Care Model (CCM) with formulation of vision for multi-stakeholder initiative • June 2006 - Battle Creek Health System convened community stakeholders to begin examining chronic care delivery in Calhoun County

4. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

5. Quality Initiative Leadership Team Consumers Employers Consumer Advisory Council Physician Advisory Council Patient Health Plans Providers Employer/Health PlanAdvisoryCouncil Stakeholders Wagner Model of Chronic Illness Care

6. Journey of Pathways toHealth Initiative • MISSION: To improve the health of Calhoun County citizens by transforming the health care delivery system and health care experience • VISION: To act as a change agent by gaining a better understanding of emerging health care needs and developing an integrated health care delivery system through the improved use of information technology

7. Journey of Pathways toHealth Initiative • October 2006 - Failed Robert Wood Johnson Aligning Forces for Quality Grant • Targets • Diabetes • Process Measures - Foot Exams, Retinal Exams • Outcome Measure - HbA1C <7 • Cardiovascular Disease • Outcome Measures - Blood pressure < 130/80, LDL in at risk population <100

8. Journey of Pathways toHealth Initiative • Targets (cont.) • Reduce Preventable Hospitalizations • Decrease gap in ethnic disparities related to diabetes and heart disease

9. Journey of Pathways to Health Initiative

10. Leadership Team Patient Consumer Other Care Providers Physicians Employer/Health Plans Chronic Care Model CHRONIC CARE MODEL

11. Leadership Team Consumer Patient Other Care Providers Physicians Employer/Health Plans • Future • Spread beyond Calhoun County • Sustainability discussion/grant proposals • National Connections – IHI, Advisory Board • Community IT • Presentations • X-prize • Cost of health care for community Demonstration community integrated IT system • Current • Advisory • Financial Support • Link to Community

12. Current • Focus groups • Virtual Consumer Advisory Council • Care Management Leadership Team • Demonstration • Vulnerable Population grant initiative Patient Other Care Providers Consumer Employer/Health Plans • Future • Virtual Consumer Advisory Council – increase utilization • Documentation ethnicity • Plan to address focus group issues • Measurementof engagement Physicians

13. V.C.A.C. V.C.A.C. V.C.A.C Members Consumers

14. Consumer Advisory CouncilCare Management Collaborative • Identified need • Assembled community care managers • Held day long education and discussion session • Developed cross-organizational teams • Included 17 organizations, 27 individuals • Impacted individual care experiences • Broke down the silos of care creating a “care across the continuum”

15. EmergencyDepartment Hospitalist ExtendedCare Facility ProviderPatientTeam ProviderPatientTeam ProviderPatientTeam ProviderPatientTeam Discharge Planner – Hospital Integrated Health Partners (IHP) Visiting Nurse Services (Lifespan) BehavioralHealth

16. ProviderPatientTeam ProviderPatientTeam ProviderPatientTeam Vulnerable Population Team EmergencyDepartment Hospitalist ExtendedCare Facility ProviderPatientTeam Discharge Planner – Hospital Integrated Health Partners (IHP) Visiting Nurse Services (Lifespan) BehavioralHealth

17. Leadership Team Consumer • Demonstration • Depression • Care Management – MI STAAR, BCBSM Care Management • Coaching Patient Other Care Providers Physicians Employer/Health Plans • Current • Learning Collaborative #1 • Learning Collaborative #2 • Patient Centered Medical Home (PCMH) • PGIP • Future • Learning Collaborative #3 • Incorporate Specialist • PCMH development • Sustainability Plan • Coaching Track • PGIP

18. Learning Collaborative

19. Physician Advisory Council • Physician Learning Collaborative 2007-2008 • 10 teams from west Michigan, year long commitment to learning and transforming the delivery of care, and engagement of patients in their care • Physician Learning Collaborative 2 2008-2009 • 26 teams from west Michigan • Outcomes Congress Oct 28,2008

20. Improvement in Outcomes – Aggregate Collaborative • Retinal Eye Exam – from 30.6% to 43.8% (42.9% improvement) • Foot Exams – from 34.3% to 60.7% (77% improvement) • Influenza Vaccine – from 31% to 62.7% (102.4% improvement) • Pneumococcal Vaccine – from 14.9% to 66.8% (347.2% improvement) • Depression Screening – from 0.8% to 39.2% (4551.4% improvement)

21. Improvement in Outcomes – Aggregate Collaborative • BP <130/80 – 29.4% to 31.9% (8.5% improvement) • HbA1c <7 – 47.5% to 50.7% (6.8% improvement) • LDL <100 – 34.8% to 42.4% (22% improvement)

22. Aggregate Collaborative 1 Trended Data

23. Aggregate Collaborative 1 Trended Data

24. Aggregate Collaborative 1 Trended Data

25. Aggregate Collaborative 1 Trended Data

26. Aggregate Collaborative 1 Trended Data

27. Leadership Team Consumer Patient Other Care Providers Physicians • Current • Value Based Benefit Design (VBBD) • Evaluation of Current Market Products • Employer Summit • Care Management Employer Health Plans • Future • ? Employer Collaborative based on zero trend • Payment reform • Workers Compensation • Demonstration • Benefit Design (VBBD) Value Based

28. Current • Care Management #1 Leadership Team • Demonstration • MI STAAR Consumer Other Care Providers Patient Lifespan Hospital Community HealthCare Connections Behavioral Health Senior Services Vulnerable Populations Physicians Employer/Health Plans • Future • Community IT • Care Management #2 • PGIP initiatives • Synergistic grant opportunity

29. Demonstration IT development • Future • Spread beyond Calhoun County • Sustainability discussion/grant proposals • National Connections – IHI, Advisory Board • Community IT • Presentations • X-prize • Cost of health care for community • Current • Advisory • Financial Support • Link to Community • Current • Focus groups • Virtual Consumer Advisory Council • Care Management Leadership Team • Demonstration • Vulnerable Population grant initiative • Current • Care Management #1 Consumer • Future • Virtual Consumer Advisory Council – increase utilization • Documentation ethnicity • Plan to address focus group issues • Measurement of engagement • Demonstration • MI STAAR Patient Other Care Providers Lifespan Hospital Community HealthCare Connections Behavioral Health Senior Services Vulnerable Populations Physicians • Future • Community IT • Care Management #2 • PGIP initiatives • Synergistic grant opportunity • Demonstration • Depression • Care Management – MI STAAR, BCBSM Care Management • Coaching • Current • Learning Collaborative #1 • Learning Collaborative #2 • Patient Centered Medical Home (PCMH) • PGIP Employer/Health Plans • Current • Value Based Benefit Design (VBBD) • Evaluation of Current Market Products • Employer Summit • Care Management • Future • ? Employer Collaborative based on zero trend • Payment reform • Workers Compensation • Future • Learning Collaborative #3 • Incorporate Specialist • PCMH development • Sustainability Plan • Coaching Track • PGIP • Demonstration • Value Based Benefit Design (VBBD)

30. Thank You Mary Ellen Benzik, MD mebstork@aol.com cell 269-580-7738 office 269-660-3850