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Patient-Centered Medical Home
Ambulatory Care for the 21st Century


   Kevin A. Dorrance, MD, FACP
   Chief, General Internal Medicine Service
   Walter Reed Bethesda




                    September 2011            7-1
Patient-Centered Care




        It’s Obvious When You See It!
                                        7-2
Patient-Centered Care




                        And When You
                            Don’t!




                                       7-3
Outcome Measures




                   7-4
Outcome Measures
    Continuous Enrollment Impact (quarterly utilization and cost)
                       Total                        Chronic                      Non-chronic
                                                     Cont                           Cont
            Average   Cont enr            Average                      Average
                                 Change               enr     Change                 enr       Change
              use      impact               use                          use
                                                    impact                         impact
IP adms     0.0351    -0.0176    -50.0%   0.0780    -0.0421   -53.9%   0.0097      -0.0032     -33.4%

IP days     0.2455    -0.1472    -59.9%   0.5440    -0.3399   -62.5%   0.0636      -0.0351     -55.1%

ER visits   0.1775    -0.0388    -21.9%   0.2828    -0.0953   -33.7%   0.0821      -0.0037     -4.5%
Specialty
            2.4688    -0.2319    -9.4%    3.4033    -0.4031   -11.8%   1.1993      -0.0519     -4.3%
care
Primary
            1.8293    -0.0190    -1.0%    2.4037    -0.0868   -3.6%    1.0023      -0.0015     -0.2%
care
Pharm.      $91.10     $4.83      5.3%    156.31    -$2.13    -1.4%     22.40       $3.43      15.3%

Ancillary   $83.42     $3.52      4.2%    118.01    -$0.43    -0.4%     43.82       $4.61      10.5%
PMPQ        $481.51   -$38.09    -7.9%    791.67    -$123.3   -15.6%   174.94       $2.46       1.4%




                                                                                                   7-5
Outcome Measures
    WRB Medical Home Impact(quarterly utilization and cost)
                      Total                        Chronic                      Non-chronic
            Average   PCMH               Average   PCMH               Average     PCMH
                                Change                       Change                           Change
              use     impact               use     impact               use       impact
IP adms     0.0215    -0.0009    -4.4%   0.0439                       0.0074

IP days     0.1016    0.0193    19.0%    0.2098     0.0393   18.7%    0.0331

ER visits   0.1574    -0.0107    -6.8%   0.2204    -0.0161    -7.3%   0.0891
Specialty
            2.2454    0.0535     2.4%    3.1946    -0.0989    -3.1%   1.0203       0.1480     14.5%
care
Primary
            1.5037    0.3199    21.3%    1.8500     0.5002   27.0%    0.9396       0.0011      0.1%
care
Pharm.      $112.16   -$14.45   -12.9%   $182.90   -$25.41   -13.4%   $27.49       -$2.35      -8.5%

Ancillary   $104.23   -$16.57   -15.9%   $144.80   -$25.06   -17.3%   $53.95       -$6.76     -12.5%
PMPQ        $507.49   -$46.67    -9.2%   $784.00   $-83.16   -10.6%   $187.44     -$13.29      -7.1%




                                                                                                   7-6
Outcome Measures
  WRB Medical Home Impact by Condition
                             Hyper-     Hyper-                      Mental
                 Diabetes   tension   lipidemia   COPD     CAD      health
IP adms                                                             -10.8%
IP days                     20.2%      19.0%               36.0%
ER visits         -13.5%
Specialty care               -3.6%     -0.5%                        3.4%
Primary care      40.3%     32.0%      32.1%      46.3%    49.3%    24.8%
Pharmacy          -17.0%    -16.1%     -17.0%     -10.3%    NA*     -1.4%
Ancillary         -16.2%    -19.1%     -15.2%     -24.0%   -24.1%   -14.1%
PMPQ              -10.5%    -11.1%     -10.0%     -10.1%            -8.2%
NNMC enrollees    1,595      7,098      7,207      960      659     2.426




                                                                             7-7
Outcome Measures
  Cost Impacts Associated with Chronic Enrollees
                                                                       Change
                                                    Non-             attributable
                                         Chronic   chronic   Total    to chronic
Estimated costs per enrollee
 PMPY without PCMH                       $3,136     $750

 PMPY with PCMH                          $2,803     $697

 Change                                   -$333     -$53
 Change                                  -10.6%    -7.1%
Average PMPY change by percent chronic
 40%                                                         -$165     80.7%
 50%                                                         -$193     86.2%
 60%                                                         -$221     90.4%


                                                                               7-8
Outcome Measures
 The Bottom Line

   Care delivered by primary care physicians in a
    patient-centered medical home is consistently
    associated with:

        Better outcomes
        Reduced mortality
        Fewer hospital admissions
        Lower utilization
        Improved patient satisfaction
        Lower Cost

                                                     7-9
Here We Are




              7-10
Here We Are
 So Young and So Many Pills
 Prescriptions for anti-hypertensives in people
    age 19 and younger could hit 5.5 million this
    year if the trend through September
    continues, according to IMS. That would be
    up 17% from 2007, the earliest year
    available. Still, a growing number of studies
    have been done under a Food and Drug
    Administration program that rewards drug
    companies for testing medications in
    children.

 Wall Street Journal, 28 Dec 2010




                                                    7-11
Here We Are
 So Young and So Many Strokes

  Researchers at the CDC analyzed hospital
   data on up to 8 million patients a year from
   1995-2008; in Annals of Neurology, they say
   stroke rates in five to 44-year-olds rose by
   about a third in under 10 years
  The rate of ischemic stroke increased by
   31% in five to 14-year-olds, from 3.2 strokes
   per 10,000 hospital cases to 4.2 per 10,000
  There were increases of 30% for people
   aged 15 to 34 and 37% in patients between
   the ages of 35 and 44
 BBC News, 2 Sep 2011


                                                   7-12
Here We Are
 US Life Expectancy at Birth, by Sex, 1900-2003




                                                  7-13
Here We Are
 US Life Expectancy at Birth, by Sex, 1900-2008



                                         If trends in
                                     chronic disease
                                    continue, we may
                                     live longer—but
                                       sicker—lives.




                                                    7-14
Here We Are
 Top 10 US Public Health Achievements

    Vaccination
    Motor vehicle safety
    Safer workplaces
    Control of infectious diseases
    Decline in deaths from coronary   Health care has had little
     heart disease and strokes         to do with increased life
    Safer and healthier foods          expectancy over time.
    Healthier mothers and babies
    Family planning
    Fluoridated drinking water
    Recognition of tobacco
     as a health hazard
                                                                    7-15
Here We Are
 Leading Causes of Death in the US

     1900                     1997
    Pneumonia        11.8%    Heart Disease   31.4%
    Tuberculosis     11.3%    Cancer          23.3%

    Diarrhea/Enteritis 8.3%   Stroke          6.9%

    Heart Disease     6.2%    COPD            4.7%
    Liver Disease     5.2%    Injuries        4.1%

    Injuries          4.2%    Pneumonia/Flu   3.7%

    Cancer            3.7%    Diabetes        2.7%

                                                      7-16
Here We Are
 Comparing Leading and Actual Causes of Death




                                                7-17
Here We Are
  Current Healthcare Model
                                   Primary
                                    Care                       Primary
                                                               Care Is
       Episodic                                               Devalued
                      Hospital                 Emergency
                                                 Room



                                                                     Disease
 Uncoordinated                                                        Model
                   Network       Specialists      Ancillary
                    Care                          Support




                  Community        Nursing       Assisted
                                   Homes          Living
                                                                               7-18
Here We Are
 The Consequences


   Episodic model of disease care
   A growing prevalence of preventable chronic
    diseases—75% of direct health care costs

    Our continuing failure to proactively monitor and improve
     the overall health of our population has facilitated the
          growth of our current disease model of care.



                                                                7-19
Here We Are
 The Yugo




              7-20
Here We Are
 Tuning the Yugo


     Disease management
     Pay for performance
     Performance-based budgeting
     Balance score cards
     Lean six sigma
     Clinical microsystems
                                    7-21
Here We Are
The Yugo




              7-22
Our Story




            7-23
Our Story
    HA PCMH implementation
                                                       Team-Based
     policy memo signed 9/1/09                      Healthcare Delivery

                                          Access
    Linking PCMH model                   to Care
                                                                          Population
                                                                            Health
     with Quadruple Aim of
     “Accountable Care”                                  Patient the
                                    Advanced             Center of             Patient-
    PCMH Resource                 IT Systems            Med Home              Centered
     Guidebook for MTFs                                                          Care

     completed
                                         Decision                         Refocused
    BUMED Primary Care                  Support                           Medical
                                          Tools                            Training
                                                        Patient &
     Instruction – “Medical Home                        Physician
                                                        Feedback
     Port” 5/26/10
    Second Annual Tri-Service
     Medical Home Summit 2010


                                                                                          7-24
Our Story
 Traditional Workflow Design
                            Chronic
          Preventive        Disease      Medication
           Medicine        Monitoring      Refills    Acute Care   Test Results




                                        PROVIDER




 Healthcare
  Support               Case        Behavioral    Medical
   Team                                                        Nursing
                       Manager        Health     Assistants
                                                                                  7-25
Our Story
  Parallel Workflow Design
                                                                        Behavior
                                                        Point of       Modification        Chronic
                                                      Care Testing                        Disease
                 Chronic               Acute
                 Disease                                          Acute                  Compliance
 Medication                   Test     Care    Preventive         Mental
                Monitoring                                                                Barriers
   Refills                   Results            Medicine          Health
                                                                 Complaint




   Healthcare
    Support                                                                           Behavioral
     Team                                                                               Health
                          Case                                  Medical
                         Manager                               Assistants
                                          Provider
                                          PROVIDER

                                                                                                   7-26
Our Story
 Health Care Delivery Team

   Team concept (clinical micropractice): IM, FM, PA/NP, RN, LPN
    and clerical support
      Collaborative: all members engaged in preventive and
        chronic care
      Team members work up to level of training
   Integrated care model
      Behavioral health into the delivery system
      Self-management support
   Proactive preventive and chronic care
      Appointing: data-driven and patient-centered
   Coordination

                                                                    7-27
Defining Access

• What is access?
• Does it = Supply – Demand?
  • Is this a simple linear relationship?




                                            7-28
Our Story
 Improved Access to Care


     In-person encounters
     Telephone
     Automated medication refills
     Secure messaging
     Telemedicine
     Open access to preventive care



                                       7-29
Our Story
 Improved Access to Care

   Reducing artificial demand
   Chronic/preventive care
      Proactive appointing and asynchronous visits
   Open access
      Patients are seen when they need to be
       and when they want to be




                                                      7-30
Our Story
 Population Health Management

  An integrated set of health delivery
  programs that proactively monitors and
  improves the fundamental health of a
  given population
   We have more personal control over what
     we are dying from than ever before.


                                             7-31
Our Story
 The Population Health Management Model


              Preventive
                Care

          Acute Care
                           At Risk

                Chronic
                 Care



    The Population
                                          7-32
Our Story
 The Integrative PCMH
   Medical home team ownership of all aspects of the
    population
   Provides patients with tools and support to improve
    their health and keep them healthy
   Includes integrated health services: psychologists,
    nutritionists, mind-body therapists and other
    professionals at the point of care
   Includes a set of IT tools and preventive measures to
    monitor outcomes and help patients take
    ownership for their own health

                                                            7-33
Our Story
 Integrated Health Services
   Programs
      Behavioral health
      Dietician
      Health education
      Mind-body medicine
      Pharmacy
   Benefits
    Provides assistance to patients when habits, behaviors,
    stress, worry or emotional concerns about physical or
    other life problems are interfering
    with their daily lives
                                                          7-34
Our Story
 Lessons Learned
   Culture change: don’t underestimate
      Training, team building
   Productivity: does it matter?
      How do we measure non-traditional care?
   Staffing model: what is optimal?
   Transformation: where to start
      Based on patient demographics
   Wellness focus: population health has to be at the
    center of all elements of care

                                                         7-35
Our Story
 Deployment Timeline

 NNMC                 Sept 2008
                                                                           ~ 2009
                                                                           Pediatric
                    Team 2 Rollout
                                                                           Department
                                         Jan 2009     Sep 2009             Implementation
     June 2008
                                        Teams 3, 4   Medical Home
   Team 1 Rollout
                                         Rollouts      Summit


 2008
                                     2009                           2010

                                                     Sep 2009          ~ 2010
                                                     NMC SD            Enhanced
                                                     Team              NMC SD MH
  Navy
                                                     Creation
 Medicine                                            Complete



                                                                                            7-36
Discussion




             7-37

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Session 7 - Patient Centered Care

  • 1. Patient-Centered Medical Home Ambulatory Care for the 21st Century Kevin A. Dorrance, MD, FACP Chief, General Internal Medicine Service Walter Reed Bethesda September 2011 7-1
  • 2. Patient-Centered Care It’s Obvious When You See It! 7-2
  • 3. Patient-Centered Care And When You Don’t! 7-3
  • 5. Outcome Measures Continuous Enrollment Impact (quarterly utilization and cost) Total Chronic Non-chronic Cont Cont Average Cont enr Average Average Change enr Change enr Change use impact use use impact impact IP adms 0.0351 -0.0176 -50.0% 0.0780 -0.0421 -53.9% 0.0097 -0.0032 -33.4% IP days 0.2455 -0.1472 -59.9% 0.5440 -0.3399 -62.5% 0.0636 -0.0351 -55.1% ER visits 0.1775 -0.0388 -21.9% 0.2828 -0.0953 -33.7% 0.0821 -0.0037 -4.5% Specialty 2.4688 -0.2319 -9.4% 3.4033 -0.4031 -11.8% 1.1993 -0.0519 -4.3% care Primary 1.8293 -0.0190 -1.0% 2.4037 -0.0868 -3.6% 1.0023 -0.0015 -0.2% care Pharm. $91.10 $4.83 5.3% 156.31 -$2.13 -1.4% 22.40 $3.43 15.3% Ancillary $83.42 $3.52 4.2% 118.01 -$0.43 -0.4% 43.82 $4.61 10.5% PMPQ $481.51 -$38.09 -7.9% 791.67 -$123.3 -15.6% 174.94 $2.46 1.4% 7-5
  • 6. Outcome Measures WRB Medical Home Impact(quarterly utilization and cost) Total Chronic Non-chronic Average PCMH Average PCMH Average PCMH Change Change Change use impact use impact use impact IP adms 0.0215 -0.0009 -4.4% 0.0439 0.0074 IP days 0.1016 0.0193 19.0% 0.2098 0.0393 18.7% 0.0331 ER visits 0.1574 -0.0107 -6.8% 0.2204 -0.0161 -7.3% 0.0891 Specialty 2.2454 0.0535 2.4% 3.1946 -0.0989 -3.1% 1.0203 0.1480 14.5% care Primary 1.5037 0.3199 21.3% 1.8500 0.5002 27.0% 0.9396 0.0011 0.1% care Pharm. $112.16 -$14.45 -12.9% $182.90 -$25.41 -13.4% $27.49 -$2.35 -8.5% Ancillary $104.23 -$16.57 -15.9% $144.80 -$25.06 -17.3% $53.95 -$6.76 -12.5% PMPQ $507.49 -$46.67 -9.2% $784.00 $-83.16 -10.6% $187.44 -$13.29 -7.1% 7-6
  • 7. Outcome Measures WRB Medical Home Impact by Condition Hyper- Hyper- Mental Diabetes tension lipidemia COPD CAD health IP adms -10.8% IP days 20.2% 19.0% 36.0% ER visits -13.5% Specialty care -3.6% -0.5% 3.4% Primary care 40.3% 32.0% 32.1% 46.3% 49.3% 24.8% Pharmacy -17.0% -16.1% -17.0% -10.3% NA* -1.4% Ancillary -16.2% -19.1% -15.2% -24.0% -24.1% -14.1% PMPQ -10.5% -11.1% -10.0% -10.1% -8.2% NNMC enrollees 1,595 7,098 7,207 960 659 2.426 7-7
  • 8. Outcome Measures Cost Impacts Associated with Chronic Enrollees Change Non- attributable Chronic chronic Total to chronic Estimated costs per enrollee PMPY without PCMH $3,136 $750 PMPY with PCMH $2,803 $697 Change -$333 -$53 Change -10.6% -7.1% Average PMPY change by percent chronic 40% -$165 80.7% 50% -$193 86.2% 60% -$221 90.4% 7-8
  • 9. Outcome Measures The Bottom Line  Care delivered by primary care physicians in a patient-centered medical home is consistently associated with:  Better outcomes  Reduced mortality  Fewer hospital admissions  Lower utilization  Improved patient satisfaction  Lower Cost 7-9
  • 10. Here We Are 7-10
  • 11. Here We Are So Young and So Many Pills Prescriptions for anti-hypertensives in people age 19 and younger could hit 5.5 million this year if the trend through September continues, according to IMS. That would be up 17% from 2007, the earliest year available. Still, a growing number of studies have been done under a Food and Drug Administration program that rewards drug companies for testing medications in children. Wall Street Journal, 28 Dec 2010 7-11
  • 12. Here We Are So Young and So Many Strokes  Researchers at the CDC analyzed hospital data on up to 8 million patients a year from 1995-2008; in Annals of Neurology, they say stroke rates in five to 44-year-olds rose by about a third in under 10 years  The rate of ischemic stroke increased by 31% in five to 14-year-olds, from 3.2 strokes per 10,000 hospital cases to 4.2 per 10,000  There were increases of 30% for people aged 15 to 34 and 37% in patients between the ages of 35 and 44 BBC News, 2 Sep 2011 7-12
  • 13. Here We Are US Life Expectancy at Birth, by Sex, 1900-2003 7-13
  • 14. Here We Are US Life Expectancy at Birth, by Sex, 1900-2008 If trends in chronic disease continue, we may live longer—but sicker—lives. 7-14
  • 15. Here We Are Top 10 US Public Health Achievements  Vaccination  Motor vehicle safety  Safer workplaces  Control of infectious diseases  Decline in deaths from coronary Health care has had little heart disease and strokes to do with increased life  Safer and healthier foods expectancy over time.  Healthier mothers and babies  Family planning  Fluoridated drinking water  Recognition of tobacco as a health hazard 7-15
  • 16. Here We Are Leading Causes of Death in the US 1900 1997 Pneumonia 11.8% Heart Disease 31.4% Tuberculosis 11.3% Cancer 23.3% Diarrhea/Enteritis 8.3% Stroke 6.9% Heart Disease 6.2% COPD 4.7% Liver Disease 5.2% Injuries 4.1% Injuries 4.2% Pneumonia/Flu 3.7% Cancer 3.7% Diabetes 2.7% 7-16
  • 17. Here We Are Comparing Leading and Actual Causes of Death 7-17
  • 18. Here We Are Current Healthcare Model Primary Care Primary Care Is Episodic Devalued Hospital Emergency Room Disease Uncoordinated Model Network Specialists Ancillary Care Support Community Nursing Assisted Homes Living 7-18
  • 19. Here We Are The Consequences  Episodic model of disease care  A growing prevalence of preventable chronic diseases—75% of direct health care costs Our continuing failure to proactively monitor and improve the overall health of our population has facilitated the growth of our current disease model of care. 7-19
  • 20. Here We Are The Yugo 7-20
  • 21. Here We Are Tuning the Yugo  Disease management  Pay for performance  Performance-based budgeting  Balance score cards  Lean six sigma  Clinical microsystems 7-21
  • 22. Here We Are The Yugo 7-22
  • 23. Our Story 7-23
  • 24. Our Story  HA PCMH implementation Team-Based policy memo signed 9/1/09 Healthcare Delivery Access  Linking PCMH model to Care Population Health with Quadruple Aim of “Accountable Care” Patient the Advanced Center of Patient-  PCMH Resource IT Systems Med Home Centered Guidebook for MTFs Care completed Decision Refocused  BUMED Primary Care Support Medical Tools Training Patient & Instruction – “Medical Home Physician Feedback Port” 5/26/10  Second Annual Tri-Service Medical Home Summit 2010 7-24
  • 25. Our Story Traditional Workflow Design Chronic Preventive Disease Medication Medicine Monitoring Refills Acute Care Test Results PROVIDER Healthcare Support Case Behavioral Medical Team Nursing Manager Health Assistants 7-25
  • 26. Our Story Parallel Workflow Design Behavior Point of Modification Chronic Care Testing Disease Chronic Acute Disease Acute Compliance Medication Test Care Preventive Mental Monitoring Barriers Refills Results Medicine Health Complaint Healthcare Support Behavioral Team Health Case Medical Manager Assistants Provider PROVIDER 7-26
  • 27. Our Story Health Care Delivery Team  Team concept (clinical micropractice): IM, FM, PA/NP, RN, LPN and clerical support  Collaborative: all members engaged in preventive and chronic care  Team members work up to level of training  Integrated care model  Behavioral health into the delivery system  Self-management support  Proactive preventive and chronic care  Appointing: data-driven and patient-centered  Coordination 7-27
  • 28. Defining Access • What is access? • Does it = Supply – Demand? • Is this a simple linear relationship? 7-28
  • 29. Our Story Improved Access to Care  In-person encounters  Telephone  Automated medication refills  Secure messaging  Telemedicine  Open access to preventive care 7-29
  • 30. Our Story Improved Access to Care  Reducing artificial demand  Chronic/preventive care  Proactive appointing and asynchronous visits  Open access  Patients are seen when they need to be and when they want to be 7-30
  • 31. Our Story Population Health Management An integrated set of health delivery programs that proactively monitors and improves the fundamental health of a given population We have more personal control over what we are dying from than ever before. 7-31
  • 32. Our Story The Population Health Management Model Preventive Care Acute Care At Risk Chronic Care The Population 7-32
  • 33. Our Story The Integrative PCMH  Medical home team ownership of all aspects of the population  Provides patients with tools and support to improve their health and keep them healthy  Includes integrated health services: psychologists, nutritionists, mind-body therapists and other professionals at the point of care  Includes a set of IT tools and preventive measures to monitor outcomes and help patients take ownership for their own health 7-33
  • 34. Our Story Integrated Health Services  Programs  Behavioral health  Dietician  Health education  Mind-body medicine  Pharmacy  Benefits Provides assistance to patients when habits, behaviors, stress, worry or emotional concerns about physical or other life problems are interfering with their daily lives 7-34
  • 35. Our Story Lessons Learned  Culture change: don’t underestimate  Training, team building  Productivity: does it matter?  How do we measure non-traditional care?  Staffing model: what is optimal?  Transformation: where to start  Based on patient demographics  Wellness focus: population health has to be at the center of all elements of care 7-35
  • 36. Our Story Deployment Timeline NNMC Sept 2008 ~ 2009 Pediatric Team 2 Rollout Department Jan 2009 Sep 2009 Implementation June 2008 Teams 3, 4 Medical Home Team 1 Rollout Rollouts Summit 2008 2009 2010 Sep 2009 ~ 2010 NMC SD Enhanced Team NMC SD MH Navy Creation Medicine Complete 7-36
  • 37. Discussion 7-37