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Primary Care Renewal: Improving Population Health, Patient Experience, and Lowering Costs

This presentation discusses the importance of patient-driven care and the role of the care team in improving outcomes. It also explores the concept of the medical home and highlights the experiences of Humboldt Independent Practice Association in transforming primary care.

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Primary Care Renewal: Improving Population Health, Patient Experience, and Lowering Costs

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  1. Primary Care Renewal“A Regional Collaboration to Improve Population Health, Individual Patient Experience, and Lower the Total Cost of Care” Alan Glaseroff MD, CMO Humboldt Independent Practice Association Humboldt ITUP Conference 12/1/09

  2. Determinants of Health and Their Contribution to Premature Death 15% Social 30% 5% Environmental 10% Medical Behavioral Genetic 40% Schroeder, NEJM 357; 12

  3. Patient Driven Care • Patients are the most important factor in their own outcomes • Patients receive care from someone they know and trust • Patients are able to access information directly • What is the role of the care team in this “Reformation”?

  4. The Care Model – “The Wheel Invented…”

  5. Core of Chronic Care

  6. “A Little Assembly Required…” • “The person who invented the wheel was pretty smart, but the person who invented the other three was a genius!” Uwe Rheinhart, Princeton Health Economist

  7. The Medical Home: It Depends on Your Point-of-View… Hospital Services Specialists Family Clinician Practice Friends and Family Internet Patients Neighborhood Gym/ Recreation Community Place of Worship Workplace The “empowered patient” view…?

  8. Humboldt • IPA • Started in 1996 • 350 member IPA (210 physicians, 80 mid-levels, 60 mental health professionals) • 7,500 HMO members, 4,000 PPO and self-funded • > 95% of all providers including safety net, average practice size 3 MDs • 84 PCPs • BOD 50/50 PCPs and specialists • Unaffiliated with hospitals • Humboldt Diabetes Project: 83% of all pts with DM in registry; NCQA Recognition for DM 2004 • “Top Quality” in CA P4P program

  9. Practice Environment in Humboldt • 25 primary care practices in various sizes, types and stages of transformation (all in the Humboldt IPA) • 2/3 of patients receive care in either FQHCs or Rural Health Clinics • 5 community health centers, Mobile Medical Clinic, United Indian Health • Many rural health clinics (small practices) • Many 1-3 clinician practices in private practices (one 17 MD Internal Medicine practice) • No large integrated multispecialty group • Managed care covering 5% of population • How to rapidly improve chronic disease care in the community?

  10. Primary Care Renewal in Humboldt • Trip to Group Health/Factoria and Care Oregon August 2008 to look at Medical Home/Care Support projects: “Build Your Own…” so we did • Dr. Ed Wagner launch 11/08 • 14 teams 1/08 • Added peer-educator team (POET) 10/09 • Model for Improvement meets “5 Aims” • Clinician “permission” • Starts with team mtgs (process measure for collaborative) • MAs as medical professionals

  11. + • Team mtgs • Model for Improvement: • Pro-active Panel Management • Preventive and chronic care measures, “closing the loop” • Access • ED visit comparative report and patient stories • Patient-Driven/Integrating Behavioral Health • POET-led session – problem-solving from patient perspective

  12. What We Have Learned So Far • Exhortation/fear of exposure/incentives not enough: “Enlightened self-interest – imagine the perfect clinical day(dream)…” • “Always start from the patient’s view” • Clinicians need • Best practices • Coaching • Comparative data/feedback • Workforce Development • MA II curriculum/certification • RN Care Support/Population Management • Peer-educators/coaches/navigators

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