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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
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
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
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
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