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1. Implementing the “Guided Care” Model of the Medical HomeAMGA 2008 Institute for Quality LeadershipSeptember 26, 2008 Professor Chad Boult, MD, MPH, MBA
Johns Hopkins Bloomberg School of Public Health
Barbara Cook, MD
President, Johns Hopkins Community Physicians
2. Guided Care The Economic Engine of the
Enhanced Medical Home
3. Guided Care Strategy:To Translate Knowledge to Practice Combine successful innovations
Integrate them into primary care
Make the model diffusible
5. The Guided Care Model Specially trained RNs based in primary physicians’ offices
GCNs collaborate with 2-5 physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health care needs
Boyd CM, Gerontologist 2007
www.GuidedCare.org
6. Guided Care Nurses’ Activities Assess needs and preferences
Create an evidence-based “care guide”
Monitor patients proactively
Support chronic disease self management
Communicate with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community
Smooth transitions between sites of care
Educate and support caregivers
Facilitate access to community services
8. Electronic Health Record Creates:
Evidence-based “Care Guides”
Reminders
Provides:
Decision support: drug interactions
Documentation of encounters
9. Identifying Vulnerable Seniors
10. Effects of Guided Care Higher quality of care
Greater physician satisfaction with care
High nurse job satisfaction
Lower caregiver strain
Lower costs of health care
23% ? in insurance payments in pilot test
$85,500 annual net savings per nurse in RCT
Boult C, J Gerontol Med Sci 2008
Boyd CM, J Gen Intern Med 2008
Sylvia M, Disease Manag 2008
Leff B (in review)
Marsteller J (in review)
Wolff J (in review)
11. Video clips
12. JOHNS HOPKINS COMMUNITY PHYSICIANS Your Home for Good Health
13. OUR VISION
TO BE THE MEDICAL HOME
FOR OUR PATIENTS
where everyone’s physical, emotional and social well being is valued and all are treated with kindness, competence and respect.
15. WHO WE ARE Part of Johns Hopkins Health System
Private, non-profit, primary care organization
Network of 17 medical centers spanning 100 mile radius throughout Maryland
143 clinicians
660 support staff
16. WHAT WE DO Patient Care
Provide primary and secondary care to over 180,000 Maryland residents.
Over 545,000 patient visits annually
Teaching
Provide practice experience for 50 medicine housestaff, 10 pediatric housestaff and 80 ACIM medical student rotations
Research
Participate in research initiatives from Johns Hopkins Schools of Medicine, Nursing and Public Health
17. COMPENSATION PLAN 65% of compensation is guaranteed
25% at risk based on productivity
10% at risk based on quality
Productivity measured by RVU’s
18. Johns Hopkins Community Physicians Payor Mix Fee for Service 76.3%
Medicare 13.9%
Medicaid 8.0%
Commercial 75.8%
Self Pay 2.3%
Capitated 23.7%
19. SURVIVING IN PRIMARY CARE There is an upper limit to pushing productivity
There is a lower limit of salary expectations; if not met, there is attrition in the primary care specialties
There is a breaking point for tolerating bureaucratic hassles in provision of care
20. FUTURE OF PRIMARY CARE Paperwork burden must be lifted
Compensation must improve
Cognitive expertise of clinicians must be valued
Crucial role in managing the care of aging population must be recognized and rewarded.
21. Primary Care in 2008 Wages
Work hours
Satisfaction
Fewer new PCPs
More early retirement
Growing workforce shortage
More chronically ill older patients
22. JHCP’s Interest in Guided Care Quality of care
Patients’ quality of life
Patients’ satisfaction with care
Providers’ professional satisfaction
Efficiency in the care of complex patients
23. JHCP’s Experience Selection of four practices:
Number of patients age 65+
Space for an RN’s office
Geographic proximity to Baltimore
Physicians’ interest
24. Implementing Guided Care Orientation of physicians and administrators
2 lunch meetings with research team
Orientation of the nurse to the physicians, the practice, and community resources
GCN course, checklist for on-site orientation
Building the Guided Care caseload (55 pts)
Care planning sessions: 20-30 minutes/pt
Ongoing Guided Care
Communication about patients, teamwork
25. Physician Satisfaction Compared to 20 control physicians, 18 Guided Care physicians reported greater satisfaction with 18/20 processes. Some were statistically significant (p < 0.05):
Educating family caregivers
Motivating patients
Knowledge of patients’ medications
26. Video clips
27. The Medical Home
28. The Medical Home Goal: to improve the quality and outcomes of chronic care
Method:
Interdisciplinary team provides chronic care services to supplement OVs
Purchasers pay practices per capita fees to offset the costs of supplemental services, plus shared savings
Evaluation:
CMS’s Medicare Medical Home Demonstration (MMHD)
Other demonstrations of the medical home
www.cms.hhs.gov
www.pcpcc.net
29. Medicare Medical Home Demo 8 states, 400 practices, 2000 physicians
Application to participate
Recognition as a medical home (tiers)
Enrollment of patients
Monthly payments per capita
Depends on the practice’s tier, the patient’s risk
Shared savings payments (80%)
Participation in the evaluation of the MMHD
30. Guided Care “Enhanced”(Tier 3) Medical Homes Provide at least 21 “medical home” services
18 required services
3 of 10 optional services
Practice infrastructure
Leadership: med. director or practice admin.
Multi-purpose electronic health record (EHR)
Guided Care nurse (RN)
LPN
31. Payments to Tier 3 Medical Homes Encounter-based FFS payments
Care management fees
~$197,000 per physician per year
Depends on size and morbidity of panel of Medicare beneficiaries with chronic conditions
Shared savings
80% of Medicare’s net saving to be shared with participating practices
CMS evaluation contractor will calculate the savings
32. MMHD Timeline Selection of implementation/evaluation contractors – by September 30, 2008
Approval by OMB
Identification of the 8 states
RFPs to practices – by April 2009
Technical assistance – by April 2009
Application and recognition as a medical home
– by November 2009
Payments and evaluation
– January 2010-December 2012
33. Technical Assistance Guided Care implementation manual
On-line course for nurses
On-line course for physicians
Guidance in selecting EHRs
Online practice self-assessment
Information by Internet and telephone
Learning collaboratives in 8 states
Consultation
34. Partner Organizations AMGA
MGMA
AAFP/TransforMED
Institute for Johns Hopkins Nursing
ANA / ANCC
35. Video clips
36. Discussion
www.GuidedCare.org