C1 Primary Care21st Century Final Presentation

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  • 1. Primary Care in the 21 st Century: The New Specialty in Health Care IHI 10 th Annual Summit on Redesigning the Clinical Office Practice March 24, 2009 Jack Cochran, MD, FACS Executive Director The Permanente Federation 510-271-4620 jack.h.cochran@kp.org Learning Objectives Participants will be able to: ° Describe how the broken health care system has altered the quality of care in the United States ° Describe how the proliferation of sources of medical information has changed the doctor- patient relationship ° Explain why Primary Care is central to achieving high quality, affordable, patient- centered care and identify the elements essential for optimizing the Primary Care experience 2 1
  • 2. quot;Our greatest responsibility is to be good ancestors.quot; Jonas Salk 3 Critical Confluence ° Affordability ° Nursing and other health care Keys to solutions worker shortages will be health care led by clinicians, ° Supply and sustainability of primary care physicians integrated with functional IT ° More patient focus/inclusion systems, and ° Essential major investments in staffed with technology and systems innovative, (including EMRs) enthusiastic, ° Government and public policy computer-enabled probing for answers health care teams. ° Baby Boomers entering Medicare ° Worst economic crisis in decades 4 2
  • 3. Can We AFFORD Not to Lead? Cumulative Changes in Premiums, Inflation, & Earnings, 2000-2006 100% 87% Health Insurance Premiums 80% 60% 40% 20% Worker's Earnings 20% Overall Inflation 18% 0% 2000 2001 2002 2003 2004 2005 2006 5 International Comparison of Spending on Health 1980-2004 Average spending on health Total expenditures on health per capita ($US PPP) as percent ofGDP 7000 16 United States Germany Canada 14 6000 France Australia United Kingdom 12 5000 10 4000 8 3000 6 2000 United States 4 Germany Canada 1000 France 2 Australia United Kingdom 0 0 80 82 84 86 88 90 92 94 96 98 00 02 04 80 82 84 86 88 90 92 94 96 98 00 02 04 19 19 19 19 19 19 19 19 19 19 20 20 20 19 19 19 19 19 19 19 19 19 19 20 20 20 Data: OECD Health Data 2005 and 2006. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006. 6 3
  • 4. Six Nation Rankings on Health System Performance AUS CAN GER NZ UK US Overall ranking 3.5 5 2 3.5 1 6 Quality care 4 6 2.5 2.5 1 5 Right Care 5 6 3 4 2 1 Safe Care 4 5 1 3 2 6 Coordinated Care 3 6 4 2 1 5 Patient-Centred Care 3 6 2 1 4 5 Access 3 5 1 2 4 6 Efficiency 4 5 3 2 1 6 Equity 2 5 4 3 1 6 Healthy Lives 1 3 2 4.5 4.5 6 Source: Commonwealth Fund (2007) 7 The Four Parts of the Quality Gap ° Overuse ° Underuse ° Misuse/Errors ° Waste 8 4
  • 5. Closing the Gap US data collated by Professor Bill Runciman, President, Australian Patient Safety Foundation from McGlynn et al; NEJM 2006 Vol 348; p2635-45 9 Dwindling Numbers # US grads entering family medicine residency 1997 2340 2006 1132 10 5
  • 6. Dwindling Numbers Career Choices of Third-Year Internal Medical Residents 11 Partially Uninsured Insured The statistics have The stories have changed a little. changed a lot. Numbers of uninsured continue to grow. 12 6
  • 7. Change quot;The committee is confident that Americans can have a health care system of the quality they need, want, and deserve. But we are also confident that this higher level of quality cannot be achieved by further stressing current systems of care. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.quot; Crossing the Quality Chasm, IOM 13 IOM's Six Major Challenges quot;Organizations will need to negotiate successfully six major challenges.quot; ° Redesigned care processes based on best evidence ° Effective use of information technology ° Knowledge and skills management ° Development of effective teams ° Coordination of care across conditions, services, and settings ° Use of performance and outcomes measurement for continuous improvement and accountability 14 7
  • 8. Crossing the Chasm to the Medical Home 15 A House is Not a Home Picker Institute Eight Dimensions of Patient-centered Care ¢ Respect for the patient's values, preferences, and expressed needs ¢ Access to care ¢ Emotional support to relieve fear and anxiety ¢ Physical comfort ¢ Involvement of family and friends ¢ Coordination of care ¢ Continuity and secure transition between health care settings ¢ Information and education 16 8
  • 9. The Old Model of Information Flow 17 What Is a Pati nt to Do with This The New Model of Abundance of Information? Inform tion Flow Graphic Graphic representing representing media alternative practitioners (e.g. acupuncturist) ? Graphic representing medical Web sites (WebMD?) 18 9
  • 10. The Future is Here Marcus Welby, MD quot;Marcia Welbyte,quot; MD 19 Patients Need a Trusted Partner Graphic representing alternative practitioners (e.g. acupuncturist) 20 10
  • 11. Essential Roles of Health Care Teams and Clinicians Healer Leader Partner 21 Patients Need a Partner to Guide Them Through the Gaps Even if you can't take care of the problem, be sure you still take care of the patient. 22 11
  • 12. We have been making Specialty Care more primary. We need to make Primary Care more special. 23 Primary Care is essential to: ° Maintain trusted, human connectivity in the patient's chaotic, complex world ° Manage and coordinate care ° Make care more affordable 24 12
  • 13. Why a Patient Centered Primary Care Practice? Research demonstrates the value of having regular access to preventive and primary care ¢ Higher quality of care ¢ Higher patient satisfaction ¢ Reduced health care disparities ¢ Lower per person cost ß Lower emergency room utilization ß Fewer hospital admissions ß Fewer unnecessary tests and procedures 25 The Value of Primary Care ¢ States with a greater ratio of generalist physicians to population had higher quality and lower costs ¢ States with a greater ratio of specialist physicians to population had lower quality and higher costs quot;Medicare Spending, The Physician Workforce, And Beneficiaries' Quality Of Carequot; Baicker and Chandra Health Affairs Web Exclusive. April 7, 2004. 26 13
  • 14. The Value of Primary Care The stronger a country's primary care system, the lower the rates of all- cause mortality, all-cause premature mortality, and cause-specific premature mortality... quot;Contribution of Primary Care to Health Systems and Healthquot; Macinko, J., B. Starfield, and L. Shi The Millbank Quarterly, Vol. 83, No. 3, 2005 27 How Do We Leverage Primary Care Physicians and Teams? Keys to making primary care more viable, desirable, and sustainable: ° Technology and tools ° Teams, including excellent relationships with specialty care ° Compensation 28 14
  • 15. Technology and Tools 29 Is Technology the Answer? OO + NT = COO It's not the box 30 15
  • 16. LO + NT = TO 31 Even with the best of intentions… GAP 200 MB capacity* 150,000 articles/month** 300,000 RCTs 20,000 biomedical journals 2,618 active performance measures 100,000 genetic tests over next few years **Ann Intern Med 2001;135:309-12 32 16
  • 17. Technology in the Hands of Physicians - Transforming Care ° Registries ° Prompts and Alerts ° Guideline Reminders ° Decision Support ° Predictive Modeling 33 Yesterday's Care Tomorrow's Care Our patients are those who make Our patients are those who are in our appointments to see us panel Patients' chief complaints or reasons We systematically assess all our for visit determines care patients' health needs to plan care Care is determined by today's Care is determined by a proactive plan problem and time available today to meet patient needs without visits Care varies by scheduled time and Care is standardized according to memory or skill of the doctor evidence-based guidelines Patients are responsible for A prepared team of professionals coordinating their own care coordinates all patients' care I know I deliver high quality care We measure our quality and make because I'm well trained rapid changes to improve it Acute care is delivered in the next Acute care is delivered by open access available appointment and walk-ins and non-visit contacts It's up to the patient to tell us what We track tests & consultations, and happened to them follow-up after ED & hospital Clinic operations center on meeting A multidisciplinary team works at the the doctor's needs top of our licenses to serve patients 34 Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma 17
  • 18. Teams (Including Excellent Relationships with Specialty Care) 35 The Power of Teams Individuals collaborate and maximize their scope of practice to provide the best care for patients ¢ Physician ¢ Nurse ¢ Medical Assistant ¢ Pharmacist ¢ Behavioralist ¢ Specialist 36 18
  • 19. The Kaiser Permanente 21 st Century Care Innovation Collaborative Model 37 The KP Proactive Encounter Experience Pre Encounter Office Encounter Post Encounter Proactive Office Encounter Management Immediate Identification • Vital sign collection / • After visit summary, • Identify missing documentation after care labs, screening • Identify and flag alerts for provider instructions, follow- procedures, access up appointments, management, kp.org • Room and prepare patient for Health Ed materials, status, etc. necessary exams how to access info • Provide member • Pre-encounter follow-up on kp.org instructions prior to Future visit • Follow-up contact • Contact member and Proactive Office Support and appointments document encounter • In-basket Management per provider in KP HealthConnect™ POE success relies upon strong physician and staff partnerships based on clearly defined roles and responsibilities, team agreements, and improved communications. 38 19
  • 20. The Kaiser Permanente Collaborative Cardiac Care Service (CCCS) Coordination among: ¢ Nursing team ¢ Cardiac rehabilitation program ¢ Pharmacy team Patients enrolled in CCCS experienced a reduced incidence of all-cause mortality by 89%. 39 Compensation 40 20
  • 21. quot;A key to the sustainability of primary care will be payment reform coupled with innovative quality measures…quot; quot;Primary Care: Too Important to Failquot; David S. Meyers, MD, and Carolyn M. Clancy, MD Annals of Internal Medicine February 17, 2009 41 quot;Patients, specialists, and the entire health system need a healthy primary care base… Primary care practice is not viable without a substantial increase in the resources available to primary care physicians.quot; quot;The Primary Care-Specialty Income Gap: Why It Mattersquot; Thomas Bodenhemier, MD, Robert A. Berenson, MD; and Paul Rudolf, MD, JD Annals of Internal Medicine February 20, 2007 42 21
  • 22. Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it's the only thing that ever has. Margaret Mead 43 Jack Cochran, MD, FACS Executive Director The Permanente Federation (510) 271-5886 fax: (510) 267-2194 email: jack.h.cochran@kp.org 44 22