Primary Care Renewal

1. Primary Care Renewal • Building Successful Practices In The Era Of Accountability • Creating Contagious Change David Labby, MD PhD Director of Clinical Support and Innovation Rebecca Ramsay, BSN MPH Senior Manager of CareSupport and Clinical Programs Santa Cruz, California May 26-27, 2011

2. Facing The Brutal Facts • What real value are we producing for the world’s greatest investment in health care? • Why does it cost 3 times more to be ranked #37 in health outcomes? • How do we justify investment in healthcare vs schools, infrastructure, social agencies etc? • The debate is now…in every state with a budget deficit… including Oregon.

3. What we have Accountability:Services/ “encounters” Historical “tribal” based roles Usually built around needs of practice and providers Rigid clinician visit centric payment model/ limited flexibility Medically resourced What is now demanded Accountability: Population outcomes/ “continuous relationships” Team “at top of license and capability” for outcomes Built around/ responsive to needs of patient/ community Empowered for continuous learning with resources, skills, aligned incentives Resourced to population needs / integrative New Primary Care System Paradigm: What Should We Really Be Doing?

4. Transformational Paradigm Shift • From historical (craft) practice: “We do it that way because this is what we do and how practice has evolved. • “What we do” = “What we’ve always done” • “Ritualism”: When you have forgotten why you are doing what you are doing… CaveHealth Well, just by looking around I can tell that you haven’t taken full advantage of many staff training opportunities…

5. Transformational Paradigm Shift • To intentional, self reflective, collective practice: “We do it that way because this is the best way so far we have figured out to accomplish our (new) strategic goals.” • Is “what we do” = “what we really should be doing?” “Insanity: doing the same thing over and over again and expecting different results.”

6. Everything I Know Is On This Slide • How We Make It Happen Every day: • Vision: what are we ALL really about? • Effective Leadership: “Bottom up top enabled” • Skills: Improvement and engineering technology • Competencies: Data management and use • Aligned Incentives: financial and cultural • Collective Learning: all of us are smarter than any of us • What We Need to Deliver That: • Know who our patients are and what they each need • Be there when they need us • Provide optimal medical management • Provide holistic person centered support • Ensure workflows / roles are (re) designed for optimal outcomes • What Is Primary Care’s New Accountability? • Demonstrate that our patients get all needed services… • ..and are not going to the ED or Hospital unnecessarily • Do it efficiently and cost effectively Ends Means Magic

7. CareOregon State Funded Health Plan for “vulnerable” citizens Medicaid: Women and Children, Disabled/ Chronically Ill Medicaid/ Medicare “Special Needs” Plan Responsible For All Physical Health Care Costs Mental Health Paid Separately 150,000 Members Not for Profit Current Contracted network 50% Safety Net CHCs Diverse Private Primary Care Practices Major metro and rural hospitals Invited Initial Participant in IHI Triple Aim Health "Triple Aim" Experience of Care Cost per Capita Our Vision: Health Oregonians regardless of their income or social circumstances. BruceDavidson

8. CareOregon/ Southcentral Foundation Delegation August 28-31, 2006 “Why can’t our community have the best health care in the world? The best health outcomes?” “How do we create intentionality in everything we do?” “How do we create the caring, knowledgeable relationships fundamental to health and healing?”

9. “Primary Care Renewal” SCF Experience: Powerful vision takes us from “Should we do it” to “How can we not do it? “SCF Model” – Agreed Basic “Design Principles:” Customer Driven Care Team Based Care Proactive Panel Health Improvement Integrated Behavioral Health Barrier Free Access Commitment to continuous learning and “intentionality” Process Improvement Training for all participants, “Coaches” CareOregon funding for clinic “pilot teams”

10. Creating Change:Who’s In Charge? (Really) • No “command and control” over network • No consensus on definition of “medical home” or “blueprint” • Recognizing we are trying to hit a target “with a bird and not an arrow…”

11. Building A Learning Collaborative Charter Meeting: Agree on Vision and Core Principles Freedom to explore how principles implemented based on context. “Step into the work” collectively: Breakthrough Series Collaborative with “Pilot” care teams Create “emergent” new knowledge through practice Establish a learning system Lead with principles, follow with tools and measures Emphasis on high yield change methods Model for Improvement/ PDSA cycles Transformation as “culture change”

12. Wild animals Biting flies Team Swamp Clinic Population Prophets Rapids Gold! • Clinic (Yr 2-3) • Spread? • In clinic, X clinic • Leadership • PCR: Steering Ctte • Clinic: Structure? • Team Coaching • Clinic data • New Payment model • Learning System? • Standardization? • Pilot Team (Yr 1) • Team? • New Roles • Coaches, BHC, Care Mgrs • Learning Groups • Panels!!! • Panel data • Division of Labor • Top of License” • Team Practices and Workflows • Huddling, Meeting, Scrubbing • BTS Collaborative • Population (Yr 2.5- ) • Primary Care Accountability? • What health, experience, cost outcomes? • New Skills & Competencies • Care Management Collaborative • Sub population Needs? • New Partnerships • Integration with other services

13. SPREAD-- Primary Care Renewal Enrolled in PCR participating clinics: ≈ 35% CO child members ≈ 45% CO adult members (as of AUG 2010)

14. Co Designed Payment Model • 2009:Quarterly payments to PCR medical home clinics based on member assigned, risk adjustment • Variable payment based on cumulative scoring: • Tier 1: Pay for participation, reporting • Tier 2: Pay for improvement / at target • Tier 3: Pay for outcomes (ED, Hospital) • 2010: Redesign with more accountability • Entry Criteria: Teams, Panels, Reporting Systems established, Workplan (per qrt/ yr) • More quarterly metrics (required / optional): continuity, access, clinical, care management metrics with cumulative scoring vs Tiers. • Annual Improvement payments: patient satisfaction, utilization (decreased ED, Hosp) • Goal: Aligning Payment System with Learning and Improvement

15. Infrastructure Development And Services (CSSI) Continuous System Improvement (Learning Ctr) Efficiency Efficiency Reallocation to Primary Care Efficiency Higher RVU PCR Payment Higher RVU Efficiency Fuels High Functioning Sustainability Efficiency Savings Inpatient Services Outpatient Services DME DX & Lab Rx Consultant Primary Primary

16. What we have learned so far… Transformational Principles • Inspire: Champion the Mission • Enable the voice and capacity of local leaders • Shift of PCR collaborative into each organization • Steering Ctte as leadership “community of practice” • Empower: Build In Improvement • Create conditions for “bottom up” change • Make time for teams to find solutions; team coaching • Organizational Collaboratives, Planning Retreats, Collective Learning • Renew: Advance Continuous Learning • Seek new knowledge and skills • Learning Commons classes on process improvement; Process Improvement Workgroup; IHI Conferences; site visits re Lean to Group Health; SNMHI • Assure: Demonstrate Accountability • Commit to measureable goals that matter • Development of PCR Payment Model metrics; Data Reporting Work Group; coaching on strategic use of measurement NHS Transformation Top Enabled… Bottom Up…

17. If Transformed Primary Care Can Do It Better… Putting More “Primary Care” Back Into Primary Care Practice • How do we shift functions done at the health plan back into Primary Care where they can potentially be done more effectively? • “CareSupport” – health plan complex care case management program • Shouldn’t this be embedded in Primary Care? • Disease Management – telephonic vendor programs vs clinic based self management supports • 2010 PCR Care Management Collaborative on depression (IMPACT model) and diabetes

18. The innovative applications really transform our experience… • Medical Home Platform: • technologically advanced • enables integration of adaptive population health applications Behav. Health Patient Centered Medical Home: A better primary care platform But the real challenge is “how do we plug them in?” Care Mgmnt Panel Mgmnt

19. Primary Care Population Health Strategies • RN/BH • Crisis Management • Care Coordination • Problem Solving • Linking with Community Resources • Supporting transitions in care • RN/BH • Self Management Support • Patient Education • Patient Activation • MA/LPN • Registries • Gaps in Care • Planned Visits 1.Panel Management 2. Care Management for 3. Complex Case Management Chronic Dz Usual Care in Primary Care Home New Potential for Primary Care Home to Transform Patient Health Outcomes

20. Medical Home Implementation Empanelment Implementation of the Basic Model Open Access Improved Telephone Access Standardized Pre-Visit Preparation Chronic Disease Management

21. Primary Care Continuity

22. Primary Care Proactive Outreach

23. Primary Care Open Access

24. Primary Care Telephone Responsiveness

25. 6 Components of Patient Centered Care In the last 6 months, how often did your health care team: LISTEN PARTNER INFO EXPLAIN RESPECT TIME

26. Overall Inpatient Utilization Rate (all-cause) The 16-18% decrease in IP stays for members being seen in PCR clinics is statistically significant and amounts to 951 fewer IP stays for these members per year. Intensive work to improve access and continuity

27. Building the capacity for care management • Care management is not a stand alone competency • Parallel work is to define team roles and workflows, and to develop protected time, resources • Segmentation of the population is a good place to start • i.e. Dz conditions, ED outreach, hospital transitions • Care management must be part of the value equation for primary care • They “want” to do it, but it’s not perceived as a “need” • Health plans have a “need” because we have found that care management effects our bottom line • Need validation and prioritization by leadership • Need aligned incentives, technical assistance, EMR tools, and training Leadership lessons learned (2009):

28. The PCR Approach to Care Management • Identified key drivers and used them to build the will and capacity • Led with evidence-based interventions • Started with pilots; encouraged site specific clinical leadership • Behavioral competencies prioritized • Team learning collaboratives • Commitment to evolve EMR to support care management practice • Quarterly reporting of both process and outcome metrics Diabetes Care Depression Care

29. Early Results: Diabetes and Depression

30. Another Type of Care Management:ED Outreach

31. Clinic-Specific ED Utilization Rates for CareOregon Members Mean ACG-PM risk score = .13 Mean ACG-PM risk score = .09

32. Overall CareOregon ED Utilization Rates

33. The Time is Now

34. Thank You! Questions?