Rob Reid: Redesigning primary care: the Group Health journey

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Rob Reid, Senior Investigator at Group Health Research Institute, explains the journey taken by Group Health in support of integrated primary care. A case study in how primary care can be delivered …

Rob Reid, Senior Investigator at Group Health Research Institute, explains the journey taken by Group Health in support of integrated primary care. A case study in how primary care can be delivered effectively and efficiently to a population, Rob laid out the challenges facing general practice in the States, and how Group Health worked to improve the situation for both patients and the workforce.

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  • The PCMH has become the policy vehicle to do this Joint principles promulgated by the main medical societies in 2007 really a major milestoneGenerally adopted by payers with many demonstrations underwayEmphasize the role of relationships, teams, whole person (not disease oriented perspectives) nature of primary care, systematic approaches to coordination and provision of quality care
  • This is the way I think about the Medical Home – since we started this work in 2006
  • Adverse consequences of speeding up primary care
  • But other changes occurring Slide tracks utilization changes per quarter
  • GHs medical home journey was borne, in 2006, before the joint principles were released. GH leadership committed to developing a prototype of a medical home redesign in one of its clinics, watching it for 2 years, and then applying the lessons learnt to revamping care in other clinics. and that’s what happened – the prototype was used to design a systemwide redesign – that was then spread to all 26 clinics, that is continuing to this day to be refined

Transcript

  • 1. Redesigning primary care: The Group Health Journey Robert Reid MD PhD Senior Investigator Group Health Research Institute The Future of Primary Care The King’s Fund September 12, 2013 London
  • 2. Group Health Collaborators Group Health Research Institute Paul Fishman PhD Clarissa Hsu PhD Eric Johnson MS Tyler Ross MA DeAnn Cromp MPH Katie Coleman MSPH Eric Larson MD MPH Ed Wagner MD MPH Michael Parchman MD MPH Dave Liss PhD Onchee Yu MS Jim Tufano PhD Kelly Ehrlich MS Group Health Cooperative / Group Health Physicians Claire Trescott MD Michael Erikson MSW Michael Soman MD MPH Alicia Eng RN MBA Barbara Trehearne RN PhD Gaguik Khatchatorian Erica Fox and many, many more….
  • 3. Funding Support • Group Health Cooperative • US Agency for Healthcare Research & Quality (AHRQ) • Patient-centered Outcomes Research Institute (PCORI)
  • 4. But, wait just a minute… • Doesn’t the US outspend all other countries in health care? • Don’t many US citizens go without healthcare insurance? • Don’t health outcomes in the US lag the UK? • Isn’t US primary care in crisis with a dominance of specialist care? • So, what could we possibly learn? • Couldn’t the King’s Fund find someone better? • Was there a last minute cancellation and he’s just a fill in?
  • 5. . 5
  • 6. The Importance of Primary Care (* adjusted for age structure, GDP, mean income, and tobacco/alcohol.) (Macinko et al, Health Serv Res 2003; 38:831-65.) High PC Countries Low PC Countries* 10,000 PYLL* 1970 1980 1990 2000 0 5,000 Ratings of Primary Care Strength and PYLL (OECD countries)
  • 7. US Primary Care Challenges  Access to primary care difficult for many, particularly disadvantaged  Quality remains mediocre at best.  Payment systems antiquated. Many valuable functions unrewarded.  Evidence-base for clinicians has become unmanageable.  Primary care unattractive career choice. Burnout common.
  • 8. The Medical Home: a Concept in Evolution Joint Principles of Patient-Centered Medical Home 2007 1. Personal physician 2. Physician-directed medical practice 3. “Whole person” orientation 4. Care is integrated & coordinated 5. Assures quality & safety 6. Enhanced access 7. Payment reform American Academy of Family Physicians. Joint Principles of a Patient-Centered Medical Home Released by Organizations Representing More than 300,000 Physicians. Position Paper, 2007
  • 9. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Community Resources and Policies Health Care Organization Improved Outcomes The Chronic Care Model Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Managed care quarterly. 1996;4(2):12-25.
  • 10. System supports for Chronic Illness Care & Prevention (info systems, practice redesign, self mgmt support, decision support) Reinvigorating Core Attributes of Primary Care (access, longitudinal relationships, comprehensiveness, coordination) Supportive physician payment methods (promotes medical home goals, not simply volume) Advanced information technologies (EMRs, registries, reminders, patient portals) Medical Home: a Concept in Evolution
  • 11. Medical Home Growth - 2008-2013 • Rapid growth of demonstrations across the US across in almost every state • Many organisations: small and large practices, hospital systems, large integrated health systems • Many Different Payers: Commercial plans, state Medicaid programs, Medicare, multi-payer demonstrations • Includes Government Systems: Veterans Health Administration, US Military • PCMH Recognition Programs: NCQA, URAC, Joint Commission • Incentives part of national Affordable Care Act • Base component of Accountable Care Organization (ACO)
  • 12. www.ncqa.org NCQA-recognized Medical Homes
  • 13. Group Health’s Medical Home Journey (so far)
  • 14. About Group Health… •Integrated healthcare insurance & delivery system started in 1947 •Revenues (2011): $3 billion •675,000 patients & many payers •10,000 staff Multispecialty Group Practice • ~1,000 MDs (PC & specialists) • 26 primary care centers • 6 specialty units, 1 hospital Contracted network • >9,000 providers, 39 hospitals Group Health Research Institute • $44 million (2010), 60 scientists • >250 active grants
  • 15. A little more history…. •Since its origin, Group Health has supported primary care •In 2000s multiple reforms to improve access, efficiency, productivity •$40 million invested in electronic clinical information systems Defined practice populations Multi-disciplinary teams Specialty care “gatekeeping” Salaried physicians “Advanced access” with same-day appointing Leaner teams, shorter visits, more visits Productivity incentives System-wide electronic medical record implementation Features “patient portal” with secure email, results review etc Decision support tools, reminders & alerts Ralston JD, Martin DP, Anderson ML, et al. Group Health Cooperative's Transformation Toward Patient-Centered Access. Med Care Res Rev. 2009;66(6):703-724
  • 16. The medical home imperative Utilization Trends 1997-2005 by Quarter Inpatient Days Specialist Visits Inpatient Admits Primary Care Visits ER Visits Access & Efficiency Reforms 1997 1998 1999 2000 2004 20052002 20032001 Frequency
  • 17. Inpatient & ER Utilization Trends 1997-2005 by Quarter Inpatient Days ER Visits Inpatient Admits Access & Efficiency Reforms 1997 1998 1999 2000 2004 20052002 20032001 The medical home imperativeFrequency
  • 18. Increasing primary care physician burnout “...the way in which [care] is structured, it has shifted such an increased amount of work onto primary care that it is not sustainable … I’m actually looking to get out of primary care because I can no longer work at this pace.” “ The burnout rate among my colleagues is huge … those of us that have managed to retain some semblance of balance do it by almost unacceptable levels of compromise, either for ourselves or what we define as good enough care.” Looming primary care workforce crisis • Many MD positions remained unfilled • Shift to part-time practice • Primary care MDs retiring earlier than specialists • Most common reason for employment separation: high workload The medical home imperative Tufano JT et al. Providers' experience with an organizational redesign initiative to promote patient-centered access: a qualitative study. J Gen Int Med. 2008;23:1778-83
  • 19. There has to be a better way! The medical home imperative
  • 20. Group Health’s Medical Home Timeline 2007 2008 2009 2010 20112006 Prototype Design Prototype Implementation & Evaluation Redevelopment & Planning for Spread Staged system-wide Spread & Evaluation of Medical Home v1.0 2012 2013 Redevelopment Medical Home v2.0
  • 21. Medical Home Design Principles (2006) The relationship between the primary care clinician & patient is at our core; the entire delivery system will orient to promote & sustain. The primary care clinician will be a leader of the clinical team, responsible for coordination of services, and together with patients will create collaborative care plans. Care will be proactive and comprehensive. Patients will be actively informed and encouraged to participate. Access will be centered on patients needs, be available by various modes, and maximize the use of technology. Our clinical and business systems are aligned to achieve the most efficient, satisfying and effective experiences.     
  • 22. Group Health’s Medical Home Prototype MD Panel size 1,800 2,300PCMH model: Enhanced & co-located Teams “Desktop” medicine time Appointments 20 min. 30 min. Value-based payment incentives
  • 23. Medical Home Staffing Changes
  • 24. 37 Medical Home Staff Roles •All outreach by any member of the team is comprehensive. For example: pharmacist call regarding medications address prevention care gaps (cancer screening).
  • 25. • Team huddles • Visual display systems • PDCA improvement cycles • Removal of RVU incentives • Calls redirected to care teams • Secure e-mail • Phone encounters • Pre-visit chart review • Collaborative care plans • EHR best practice alerts • EHR prevention reminders • Defined team roles Point-of-care changes • ED & urgent care visits • Hospital discharges • Quality deficiency reports • e-health risk assessment • Birthday reminder letters • Medication management • New patients Patient-centered outreach Management & payment PCMH Model Group Health’s PCMH Prototype
  • 26. PCMH Prototype Evaluation Patient experience Staff burnout Evaluation measures: Quality Utilization Cost     • Quasiexperimental, non-randomized intervention & matched control study design with baseline and follow-up data collection at 1 & 2 years • 2 control clinics for patient & staff surveys; 19 control clinics for administrative data analyses
  • 27. Reid RJ et al, Health Affairs 2010;29(5):835-43 Reid RJ et al, Am J Manag Care 2009;15(9):e71-87 Medical Home Components  Year 1: 94% more emails, 12% more phone consultations, 10% fewer calls to consulting nurse, & other changes  Year 2: Changes persisted Patient Experience  Year 1: small, statistically significant changes in 6/7 scales including access, quality of MD interactions, care planning  Year 2:Changes persisted in 5/7 scales MD & Staff Burnout  Year 1: Emotional exhaustion dropped by half at medical home with no change in controls.  Year 2: Changes lessened but remained significant Utilization  Year 1: 29% fewer ER visits, 11% fewer preventable hospitalizations, 6% fewer but longer in-person visits  Year 2: Significant changes persisted Costs  Year 1: No significant difference in total costs between Medical Home and control patients  Year 2: Lower patient care costs approached stat significance (~$10 PMPM; p=0.08) PCMH Prototype Evaluation
  • 28. New questions emerge…  Are the results generalisable to Group Health’s other clinics?  What will happen when practices don’t “invent” it?  What spread methods to use & how to stage?  Are the leaders & managers up to the task?
  • 29. STAGED SPREAD OF PRACTICE CHANGE MODULES Call Management Team Huddles Standard Mgmt Practices Enhanced Staffing Model Value-based MD Payment Model SUPPORTED BY CHANGES TO MANAGEMENT, STAFFING AND MD PAYMENT Standardization & Spread using LEAN Techniques & Tools Group Health’s PCMH Spread Virtual Medicine Care Management Visit Preparation Patient Outreach
  • 30. Evaluating the Medical Home Spread • Process Evaluation - implementation change targets met for most of the PCMH modules across all clinics Hsu C, Coleman K, Ross TR, et al. J Amb Care Manage. 2012;35(2):99-108
  • 31. Evaluating the Medical Home Spread Reid RJ, Johnson EA, Hsu C, et al. Ann Fam Med 2013;11:S19-S26 Phone  E-mail   Face-to-face
  • 32. Evaluating the Medical Home Spread Reid RJ, Johnson EA, Hsu C, et al. Ann Fam Med 2013;11:S19-S26 ✗ ✔ ✔
  • 33. Learning Healthcare System Green SM, Reid RJ, Larson EB. Implementing the learning health system: from concept to action. Ann Intern Med 2012;157:207-210
  • 34. Next Steps: Medical Home version 2.0 Key Changes to Group Health’s Medical Home :  Patient-risk Stratification to better target human resources  Move team members to practice at “top of licensure”  Strengthening the primary care teams: “relational coordination theory”  Integrating with the Medical Neighborhood: integrating mental health, chemical dependency, and specialty care into in the primary care teams  Developing a patient-centered community liaison role
  • 35. Some final thoughts…. • Redesign represents significant change in how doctors, nurses & care team members think about their job • Patient needs, desires, and perspectives should be primary • Primary care physicians & team members need to “own” the changes and it must “work” for them • Strong leadership and management is key • Invest in a long term journey with many improvement cycles
  • 36. Thank you Rob Reid reid.rj@ghc.org Questions??