Session 7 - Patient Centered Care

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Session 7 - Patient Centered Care

  1. 1. Patient-Centered Medical HomeAmbulatory Care for the 21st Century Kevin A. Dorrance, MD, FACP Chief, General Internal Medicine Service Walter Reed Bethesda September 2011 7-1
  2. 2. Patient-Centered Care It’s Obvious When You See It! 7-2
  3. 3. Patient-Centered Care And When You Don’t! 7-3
  4. 4. Outcome Measures 7-4
  5. 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 impactIP 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%carePrimary 1.8293 -0.0190 -1.0% 2.4037 -0.0868 -3.6% 1.0023 -0.0015 -0.2%carePharm. $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. 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 impactIP adms 0.0215 -0.0009 -4.4% 0.0439 0.0074IP days 0.1016 0.0193 19.0% 0.2098 0.0393 18.7% 0.0331ER visits 0.1574 -0.0107 -6.8% 0.2204 -0.0161 -7.3% 0.0891Specialty 2.2454 0.0535 2.4% 3.1946 -0.0989 -3.1% 1.0203 0.1480 14.5%carePrimary 1.5037 0.3199 21.3% 1.8500 0.5002 27.0% 0.9396 0.0011 0.1%carePharm. $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. 7. Outcome Measures WRB Medical Home Impact by Condition Hyper- Hyper- Mental Diabetes tension lipidemia COPD CAD healthIP 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. 8. Outcome Measures Cost Impacts Associated with Chronic Enrollees Change Non- attributable Chronic chronic Total to chronicEstimated 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. 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. 10. Here We Are 7-10
  11. 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. 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. 13. Here We Are US Life Expectancy at Birth, by Sex, 1900-2003 7-13
  14. 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. 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. 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. 17. Here We Are Comparing Leading and Actual Causes of Death 7-17
  18. 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. 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. 20. Here We Are The Yugo 7-20
  21. 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. 22. Here We AreThe Yugo 7-22
  23. 23. Our Story 7-23
  24. 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. 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. 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. 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. 28. Defining Access• What is access?• Does it = Supply – Demand? • Is this a simple linear relationship? 7-28
  29. 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. 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. 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. 32. Our Story The Population Health Management Model Preventive Care Acute Care At Risk Chronic Care The Population 7-32
  33. 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. 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. 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. 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. 37. Discussion 7-37

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