Project Summary: Washington Patient-Centered Medical Home Collaborative

1. Project Summary: Washington Patient-Centered Medical Home Collaborative Pat Justis, MA Department of Health

2. Objectives • Briefly summarize the project goals, structure ,activities, and participants • Provide an initial look at results • Provide information related to accreditation and the national work on medical home • Discuss key lessons

3. DOH • Seven collaboratives since 1999 • Diabetes • Later hypertension, asthma, youth obesity, medical home • Partners • Qualis Health • Improving Chronic Illness Care (ICIC) funded by Robert Wood Johnson Foundation. • Acumentra Health, University of WA • Washington Academy of Family Physicians

4. Washington Patient-Centered Medical Home Collaborative • 33 teams began, 31 finished. • 24 months, 2009-2011 • Five learning sessions/ 8 full days • Five plus site visits by Quality Improvement Coach • Monthly webinars/e- news bulletins • Reporting of data and narrative reports • Ongoing support by e-mail/phone/website

5. What are we trying to accomplish? The Mission To implement medical homes in a variety of primary care clinics and improve the care of patients/families using the collaborative methodology.

6. Goals • Develop an implementation model for primary care medical home which: • Improves health outcomes for patients • Improves the patient and family’s experience of care • Improves primary care team satisfaction • Examine overall health care utilization and costs impacted by medical home implementation.

7. The “other” medical home legislation-2009Health Care Authority/Puget Sound Health Alliance • Separate but “connected” payer demonstration with anti-trust safe harbor. • 12 practice sites/8 organizations • 9 of 31 Collaborative teams participating • Official start-May 2, 2011 • 26,000 attributed patients • Now collecting data on first two months.

9. Total number of providers, all Collaborative sites=755 providers

10. Population density surrounding participating clinics

11. Patients at participating sites by age groupTotal estimated patients, all ages= 738,111

12. Early evidence suggests… • Patient satisfaction improves. • Provider satisfaction improves. • Burn-out decreases. • Avoidable emergency room visits decrease. • Clinical outcomes improve. • Cost savings or neutralizes cost increase.

13. Measure synopsis • Patient experience-flat in aggregate, individual clinics made significant gains • Provider/team satisfaction • Clinical measures-many clinics have significant progress • Prevention • Diabetes • Medical Home Index-improved steadily

14. Medical Home Index

15. Relationships between measures/ clinic characteristics • To be explored in final analysis • Do clinic traits correlate with any particular findings? • Are there any connections between the various measures, for example do high medical home index scores associate with improved clinical outcomes?

16. Medical Home Indexheadlines • Some clinics may overestimate their own scores, others may be too self-critical. • The scores between clinics are not a useful comparison. • Use as a tool to stimulate understanding, continual self-assessment and instigate quality improvement.

17. The tools • Medical Home Index-adult and peds (MHI) (Center for Medical Home Improvement) • Patient-Centered Medical Home Assessment (PCMH-A) ( Safety Net Medical Home Initiative) • Medical Home Implementation Quotient (MHIQ) ( Transform Med-AAFP profit arm) • http://www.urban.org/uploadedpdf/412338-patient-centered-medical-home-rec-tools.pdf

18. The accreditation quandary • Newly revised NCQA PCMH standards • Joint Commission has new voluntary standards for “primary care homes.” • States with state legislated accreditation: Oregon, Minnesota • Tools : Medical Home Index, Transform Med, The Patient-Centered Medical Home Assessment , and more.

19. States with the most activity; rapidly spreading • Colorado • Vermont • New Hampshire • Michigan • Maine • New York • North Carolina • North Dakota • Minnesota • Ohio • Texas • Arizona • Louisiana • Pennsylvania • Rhode Island • Georgia • Tennessee • Illinois

20. Health Home Bill 5394 (2011) “To promote the adoption of primary care health homes for children and adults and, within them advance the practice of chronic care management to improve health outcomes and reduce unnecessary costs. “

21. Health Home Bill 5394 (2011) • Payers must offer incentives for quality and adoption of health home, care of chronic disease to providers. • Affects all plans under HCA, including PEBB plans • Payment to support providers to participate in training and technical assistance.

22. DOH role with 5394 • Training and technical assistance for providers of primary care; • Related to evidence based high quality preventive and chronic disease care • In collaboration with Health Care Authority

23. Section 2703 Affordable care act • 5% of Medicaid clients responsible for 50% of costs. • Scale up and spread existing demonstrations. • Team based care coordination with behavioral health integration. • Remove funding silo barriers.

24. Ongoing challenges • Accreditation vs. quality measures • Payment reform: risk, patient choice, gains sharing, transition between FFS and bundles and or PMPM • Solo providers and networks • Payers ability to test models • Transitions :cross-setting improvements

25. Workforce puzzles • Scope of practice for medical assistant wildly variable. • What helps physicians transform leadership to a team facilitation style? • Better integration of pharmacists. • More intentional change to role of RN • Shortage of primary care providers/nurses

26. The Transform Med Demonstration lessons • Clinic autonomy • Adaptive reserve • Transformative level of change • Changes are linked and interdependent

27. Lessons learned • Every funder wants a pet measure; this places an undesirable burden; must find root drivers, proxies, alignment etc. • Data must be in the hands of the team; and organizations vary in this ability. • EMR’s vary widely in registry like functions for population management

28. Health literacy A large, fundamental paradigm shift related to who has the responsibility to create understanding.

29. Relationships are the center • Providers and teams • Teams and other teams • Provider/Team and patients/families • Across care settings and transitions in care. • Continuity of relationship is patient-centered and must trump convenience and provider schedule preferences.

30. Lessons • Teamwork is a learned skill, not an innate ability. • Facilitative leadership comes easier to some than others but begins with willingness to develop trust.

31. What is ahead? • Age specific/ • Peds involvement • Community based and across settings • Rural • Behavioral health • Prevention of chronic conditions • Scalable; more teams, more open enrollment. • Testing face-face “dosage” • More linkage between education and coaching. • Cross-setting improvements