Patient Centered Medical Home

1. Patient Centered Medical Home Susana A. Alfonso, M.D., M.H.C.M. June 3, 2010

2. Learning Objectives • Describe in broad terms what the PCMH is • Describe why this transformation is needed • Describe the relationship between cost and quality • Increase awareness of what’s happening at Emory with the PCMH

3. Why do this at Emory Family Medicine? Patty has been seen by Cardiology, Cardiothoracic Surgery, Nephrology, Pulmonology, Vascular Surgery, Behavior Medicine, and the Source Care Management Program at Wesley Woods

4. What is it? • A new way to provide primary care • Incorporates the “old” principles of primary care • Leverages new technology, team based approaches, open access…

5. Joint Principles of the PCMH (February 2007) • The following principles were written and agreed upon by the four Primary Care Physician Organizations – the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association. • Principles: Ongoing relationship with personal physician Physician directed medical practice Whole person orientation Coordinated care across the health system Quality and safety Enhanced access to care Payment recognizes the value added

6. History of the Medical Home Concept • The first known documentation of the term “medical home” Standards of Child Health Care, AAP in 1967 by the AAP Council on Pediatric Practice -- “medical home -- one central source of a child’s pediatric records” History of the Medical Home Concept Calvin Sia, Thomas F. Tonniges, Elizabeth Osterhus and Sharon Taba Pediatrics 2004;113;1473-1478

7. Source: Aaron Catlin et al., “National Health Spending in 2006: A Year of Change for Prescription Drugs,” Health Affairs (January/February 2008). Used with permission from Karen Quigley, Harvard School of Public Health. Lecture “Payment Systems the Big Picture” 09/08.

8. Average health spending per capita ($US PPP) Source: 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, updated with 2007 OECD data

10. Mortality Amenable to Health Care Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care Deaths per 100,000 population* International variation, 1998 State variation,2002 Percentiles * Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease. See Technical Appendix for list of conditions considered amenable to health care in the analysis. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006. Data: International estimates—World Health Organization, WHO mortality database (Nolte and McKee 2003); State estimates—K. Hempstead, Rutgers University using Nolte and McKee methodology.

14. What is the Commonwealth Fund?? • “The Commonwealth Fund is a private foundation that aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.” http://www.commonwealthfund.org/About-Us.aspx (accessed 11 January 2010)

15. Donald Berwick-Escape Fire “The errors were not rare; they were the norm. During one admission, the neurologist told us in the morning, “By no means should you be getting anticholinergic agents,” and a medication with profound anticholinergic side effects was given that afternoon. The attending neurologist in another admission told us by phone that a crucial and potentially toxic drug should be started immediately. He said, “Time is of the essence.”That was on Thursday morning at 10:00 a.m. The first dose was given 60 hours later—Saturday night at 10:00 p.m. Nothing I could do, nothing I did, nothing I could think of made any difference.”

16. VALUE = Quality/Cost

18. Transforming the Delivery of Primary Care Patient and Family Centered Medical Home Improved Health Care Health Navigator Personalized Health Plan Institute of Medicine

19. “The Right Care At the Right Time By the Right Person With The Right Information”

20. Patient and Family Centered Medical Home • Providing the right care at the right time in the right place for THE PATIENT • Joint Principles (AAFP, ACP, AAP, AOA) • Personal physician • Physician directed medical practice • Whole person orientation • Care is coordinatedand/or integrated • Quality and safety • Enhanced access • Payment • Value driven (IHI: Berwick) • Improve the health of the population (measure outcomes) • Enhance the patient experience of care (including quality, access, and reliability);   • Reduce, or at least control, the per capita cost of care. • Robust Health IT infrastructure

21. TRANSFORMED FACILITATION ARM OF THE AAFP

22. Defining the Medical Home • Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs. Publically available information www.pcpcc.net/content/general-presentation-materials Source: Health2 Resources 9.30.08 8

23. TODAY’S CARE MEDICAL HOME CARE My patients are those who make appointments to see me Our patients are those who are registered in our medical home Patients’ chief complaints or reasons for visit determines care We systematically assess all our patients’ health needs to plan care Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet patient needs without visits Care varies by scheduled time and memory or skill of the doctor Care is standardized according to evidence-based guidelines Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care I know I deliver high quality care because I’m well trained We measure our quality and make rapid changes to improve it Acute care is delivered in the next available appointment or walk-ins Acute care is delivered by open access and non-visit contacts It’s up to the patient to tell us what happened to them We track tests & consultations, and follow-up after ED & hospital Clinic operations center on meeting the doctor’s needs A multidisciplinary team works at the top of our licenses to serve patients Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

24. INFORMATION WITHIN THE OFFICE • Ensure the RIGHT care • Clinical decision support • Preventive reminders • Referral and lab ordering and tracking • Medication reconciliation/alerts • Measure the RIGHT care • Quality metrics • Registries • Who’s not getting the RIGHT care

25. INFORMATION FLOW OUTSIDE THE OFFICE • Specialists • Pharmacies • Hospitals

26. INFORMATION FLOW TO THE PATIENT • Portal for appointments • Patient education/Group Visits • Email communication with care team • Lab and ancillary testing results • Direct access to the medical record- • Transparency • Automated patient history Bachman, John. 2008. Improving Care with an Automated Patient History. Practice Improvement Anthologies. Pp. 55-59. AAFP.

27. Interface with Specialty Care • Service Agreements • Personal Relationships • Speed Dating • Protocols for referrals • “Specialists don’t want to see inappropriate or unnecessary referrals and are willing to try other venues like phone consults and get paid for them.” Paul Grundy. PCMH for Employees. Meeting with Emory University Human Resources: August 12, 2009.

28. Providing Seamless Care Between Primary Care and Specialists. Presented at Institute for Healthcare Improvement 11th Annual International Summit on Improving Care in the Office Practice & The Community March 9, 2010. Michael S. Barr, MD, MBA, FACP Vice President, Practice Advocacy & Improvement Division of Governmental Affairs & Public Policy

29. Interface with Specialty Care “ACOs (Accountable Care Organizations) will require a strong primary care core to succeed and, in turn, can provide essential delivery-system infrastructure beyond the primary care practice to ensure the full realization of the PCMH model.” Rittenhouse, Diane R., Stephen M. Shortell, and Elliott S. Fisher. 2009. Primary Care and Accountable Care-Two Essential Elements of Delivery System Reform. Published on October 28 at NEJM.org.

30. Who can transform themselves into a Patient Centered Medical Home? • Physician Eligibility Includes family practice, internal medicine, geriatrics, general practice, specialty and sub-specialty practices (except where specifically excluded). • Excluded specialties and subspecialties include radiology, pathology, anesthesiology, dermatology, ophthalmology, emergency medicine, chiropractic, psychiatry, and surgery. Medical Home Demonstration Fact Sheet. As of January 9, 2009. medhome_factsheetCMS.pdf.

31. PPC-PCMH Content and Scoring **Must Pass Elements

32. NCQA PCMH Must Pass Elements • PPC1A: Written standards for patient access and patient communication • PPC1B: Use of data to show meeting standards • PPC2D: Use of paper or electronic-based charting tools to organize clinical information-Complete • PPC2E: Use of data to identify important diagnoses and conditions in practice • PPC3A: Adoption and implementation of evidence-based guidelines for three conditions • PPC4B: Active support of patient self-management • PPC6A: Tracking system to test and identify abnormal results-Complete • PPC7A: Tracking referrals with paper-based or electronic system-Complete • PPC8A: Measurement of clinical and/or service performance-Complete • PPC8C: Performance reporting by physician or across the practice-Complete

33. Reimbursement Models • A prospective, bundled component that covers physician and administrative staff work and practice expenses linked to the delivery of services under the PCMH model not covered by the most current Medicare RBRVS system. • A visit-based fee component for services delivered as part of a face-to-face visit and that are already recognized by the most current Medicare RBRVS system. • A performance-based component based on the achievement of defined quality and efficiency goals as reflected on evidence-based quality, cost of care and patient experience measures. • The payment model should recognize differences in the level of PCMH care provided and patient case mix/complexity Guidelines for PCMH Demonstration Projects. PC-PCC Endorsed March 2009. pcmh_demo-guidelines.pdf

34. Reimbursement Models • Bridges to Excellence (BTE)-Aetna: Certification entitles practioner to incentives. • Geisinger: Geisinger Health Plan paid • $1800/ month per physician to “recognize expanded scope of practice” • “Transformation stipend” of $5000/mo per 1000 Medicare members • Incentive pool based on difference between actual and expected total costs of care Paulus, Ronald A., Karen Davis, and Glenn D. Steele. 2008. Continuous Innovation in Healthcare: Implications of the Geisinger Experience. Health Affairs, 27.5: 1238.

35. Reimbursement Models-Aetna “Aetna is engaged in four Patient Centered Medical Home demonstrations and is planning several others. In each of these, payment structures can range from allowing payment for care coordination services and consultation within an interdisciplinary team to innovative gainsharing strategies. In our Medicare Advantage program we also are making nurse care coordinators available on-site at physician offices to support primary care. “ Testimony of Ronald A. Williams Chairman and Chief Executive Officer, Aetna Inc. before the United States Senate Committee on Finance “Delivery System Reform” Tuesday, April 21, 2009 [Written Submission ]

36. Evidence of Cost Savings & Quality Improvement • Barbara Starfield of Johns Hopkins University • Within the United States, adults with a primary care physician rather than a specialist had 33 percent lower costs of care and were 19 percent less likely to die. • In both England and the United States, each additional primary care physician per 10,000 persons is associated with a decrease in mortality rate of 3 to 10 percent. • In the United States, an increase of just one primary care physician is associated with 1.44 fewer deaths per 10,000 persons. • Center for Evaluative Clinical Sciences at Dartmouth, states in the US relying more on primary care have: • lower Medicare spending, • lower resource inputs, • lower utilization, and • better quality of care. Starfield, Barbara, Leiyu Shi, and James Macinko. 2005. Contribution of Primary Care to Health Systems And Health. The Milbank Quarterly, 83.5: 457-502.

37. www.pcpcc.net/content/general-presentation-materials

38. What’s going on at Emory?? • Alternative Care Committee • PCMH Working Group • Family Medicine, Internal Medicine collaboration to develop two pilots at Emory • Aetna • Cerner

39. Learn More about the PCMH • Visit the PCPCC www.pcpcc.net or • TransforMed http://www.transformed.com/whoweare.cfm • View a brief (4 minutes) video clipabout the Patient Centered Medical Home www.fpm.emory.edu

40. What can you do? • www.aafp.org- Connect for Reform • Be sensitive to people’s fears • Most people resist change • Seek mentors/advisors • Look nationally

41. Thank You! salfons@emory.edu