VA NWI & V23 Medical Home Pilot

1. VA NWI & V23 Medical Home Pilot Michael S. Hein, MD, MS, FACP Medical Director, VA Midwest Health Care Network, V23 Primary Care and Specialty Medicine Service Line Minneapolis, MN

2. VISN 23 Existing Outreach Clinics Planned Outreach Clinics

3. VISN 23 Data Summary • FTEE 11,196 • Patients Served 290,485 • Women Veterans Served 18,434 • Outpatient Visits 2,514,579 • Budget $1,987,592,774 • Medical/Surgical Average Daily Census (ADC) 300.2 • Psychiatry ADC 52.2 • Community Living Center ADC 560.5 • Domiciliary ADC 181.9 • PRRPT ADC 90.8 • Health Care Systems 8 • CBOCs 44 • Outreach Clinics 2 • Vet Centers 14

4. Veterans

5. Nebraska-Western Iowa HCS • VA - Grand Island, Nebraska (Central) • Integrated Health System (VANWIHCS) • GRI, Omaha, Lincoln and 5 CBOC’s ~ 45,000 PCP patients • Rural Community – pop. 45,000 • Serves • Western and Central Nebraska • Northern Kansas • Grand Island ~ 13,000 patients • Additional services: Nursing Home, Therapy, Mental Health, Residential Treatment, two CBOC’s, Pharmacy, Lab, Radiology

6. Joint Principles of the Patient-Centered Medical Home AAFP, AAP, ACP, AOA Ongoing relationship with personal physician Physician directed medical practice Whole person orientation Enhanced access to care Coordinated care across the health system Quality and safety Payment 6

7. Primary Care in the VA • EMR (CPRS) – Fully Integrated; ‘Paperless’ • Pharmacy Clinics – Clinical Pharmacists • Chronic Disease Management (Wagner Model) • 1.0 – 3.0 (2.2) PC Support Staff to 1.0 Provider FTE • Ubiquitous Clinical Metrics, including HEDIS • CAHPS Satisfaction/Experience Scores • Costs – Pharmacy, Lab, Imaging, Clinical Services • Integrated (co-located) MH services • Patients Assigned to PCP: Max Panel = 1200

8. Medical Home Pilot Time Frame • Conceived Spring of 2008 • Proposal for local Innovation Grant – Approved • Imbedded project into IHI Triple Aim – Phase II • June 2008, Team Formation and Planning Begins • September 1, 2008, PCMH Clinic ‘opens’ • Spread to next core teams – September 2009

9. Inspiration: Quality Delvin McMillian, 28, a retired airman from Bessemer, Ala., spins away from his pursuers in a quad rugby game at the 28th National Veterans Wheelchair Games, held July 25 through 29 (2008) in Omaha, NE. Photo by David E. Klutho, Sports Illustrated

10. The Core Team (Micro-Clinic) • Clerks/Schedulers x 2 • LPN x 3 (4) • RN x 1 • Providers x 5 (2.9 PC FTE) • 3 x MD • 1 x PA, 1 x APRN • ~ 2,800 patients • Staffing ration = 2.0 to 2.3 FTE/PC FTE

11. The Team (clinic-wide) • Chronic Disease Management Nursing (Wagner) • EMR (CPRS) support staff • Data Analyst • Social Work* • Clinical Pharmacy* • Mental Health – partially integrated • Leadership - Nursing, Administrative, Clinical • Newly added – Co-management Office

12. Example Medical Home – NWI Grand Island Medical Home HBPC (75) CBOC-NP (3000) Core Team-2 (4200) Core Team-1 (2800) Core Team-3 (1000) CBOC-H (2000) (Approx. no. of Patients) Clinical Microsystems GRI – Medical Home NWI

13. Approach Team, System Redesign, Medical Home Principles

14. Constructing Exceptional Primary Care Leadership Leadership TIME

15. Team Development and Function • Roles and Responsibilities • Conflict Resolution • Effective and Safe Communication • Personalities – Strengths Assessment • Developing a Shared Charter/Vision • Working together • Planning, Implementation, System Redesign • Measurement of ‘Team’

16. System Redesign at the Front Line • PDSA Rapid Cycle Improvement • Basic LEAN principles – Flow mapping, measuring • Weekly Data Driven Decisions • Open Access – Reinforcing principles • Continuous Panel Management • Weekly (1-hr) Performance-based Meetings • Data Acquisition and Presentation

17. Time • Pre-training and Education • Weekly to bi-monthly ½ to 1 day sessions (3 months) • Weekly Team Meetings • Quarterly Breakouts • Daily Decisions • Care Management and Coordination • Non-face to face care frees up some clinic time • Open Access Scheduling • Continuously and rigorously applied • Daily Huddles

18. Performance

25. The Use of Data • What you measure = how you will Act • Timely – frequently enough • Actionable – team knows what it means • Accurate – not flawless, but reasonable • Continuously Maturing • Measurement • Is it measuring what you want to change? • Is it sensitive enough to show change? • Is it measuring patient-centered view, or health system view?

26. Key Lessons Learned (ing) • Measuring Team Dynamic – Performance • Leadership • Good Data in the Hands of Good People • High Performing Team Dynamic – Limited/Cyclical • Nutting et.al. NDP and “Adaptive Reserve” • Time – Commerce of the Medical Home • We Were not Patient-Centered Enough

27. What’s Next – National/Regional • History of Primary Care in the VA – 10 year • Pulling all of the pieces together • National and Regional (VISN) efforts • Universal Services Task Force Report • Care Coordination and Chronic Disease Management • National Implementation • System Redesign at the Front-line • Team Dynamic and Function

28. What’s Next - Local • Spread • 2 patients on the Core Team weekly meetings • Or a patient council • Coordination of Care – Dual Care Focus • Continuous Learning – Working in Team • Measurement (drives change): Health, Cost, Patient Experience • Team Function/Dynamic • “Hominess”

29. Unsolicited Advice • The principles of Medical Home should guide action • Create a multidisciplinary high performing team • Share a Vision that is focused on Quality and Safety • Be knowledgeable about process, flow, and improvement science => gained efficiencies. • Pick the ‘low hanging fruit’ – measure • Involve patients • Be data driven • Celebrate Successes • Learn, evolve, and don’t avoid ‘failure’

30. "If you're not failing every now and again, it's a sign you're not doing anything very innovative.“ Woody Allen Advice

31. References • Nutting, P., et.al. Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home. Ann Fam Med 2009;7:254-260. • Reid, R.J., et.al. Patient-Centered Medical Home Demonstration: A Prospective, Quasi-Experimental, Before and After Evaluation. Am J Manag Care. 2009;15(9):e71-e87. • C00ley, W.C., et.al. Improved Outcomes Associated with Medical Home Implementation in Pediatric Primary Care. Pediatrics 2009;124;358-364.