Rutgers april 2014


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Summary -- Patient Centered Medical Home the Necessary Foundation for Accountable Care and Population Management.

In the next 10 years, we will be living in 1) mobile world 2) in the middle of an aging and chronic disease epidemic and 3) data. But , we will also have the ability to analyze data in a cognitive way this will do for doctors’ minds what X-ray and medical imaging have done for their vision. How? By turning data into actionable information. Take, for instance, IBM’s intelligent supercomputer, Watson. Watson can analyze the meaning and con-text of human language and quickly process vast amounts of information. With this in-formation, it can suggest options targeted to a patient’s specific circumstances.
We need the basic foundation to support this transformation a system integrator where data at the level of a patients flows and is held accountable and that model is the Patient Centered Medical Home. (PCMH) starts to happen when clinicians/ healers step up to comprehensive relationship based care empowered by tools to manage the data and communicate effectively. This move to PCMH level care requires the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system and all of that is power by data made into meaningful information.
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
The Patient-Centered Medical Home (PCMH) lies at the center of the effort to get at population health, integrated and coordinated care. PCMH is where the Primary care healer leads an organization that delivers clinician-led primary care, with comprehensive, accessible, holistic, coordinated, evidence-based coordination and management. In the USA this is now the standard in the US Veterans Administration and the US Military and under the ACA.

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Rutgers april 2014

  1. 1. © 2014 IBM Corporation Smarter Care Paul Grundy MD, MPH - IBM Director, Healthcare Transformation March, 2014 Quality Primary Care. Reducing Costs, Improving Care Patient Centered Medical Home
  2. 2. © 2014 IBM Corporation 2 Smarter Care Paul Grundy MD MPH Bio • “Godfather” of the Patient Centered Medical Home • IBM Global Director Healthcare Transformation • President of PCPCC • Member Institute of Medicine • Member Board ACGME • Professor Univ. of Utah Department Family Medicine • Winner NCQA national Quality Award • A Leader of MOH level taskforce primary care transformation 8 nations: USA, Canada, New Zealand, Australia, Holland, Denmark, UK, Belgium, • Univ. of California MD, John Hopkins Trained
  3. 3. © 2014 IBM Corporation 3 Smarter Care
  4. 4. © 2014 IBM Corporation 4 Smarter Care Reengineering for Health Care Three types of businesses undertake reengineering: • Those at the peak of their game & ambitious executives •those that reengineer to stay ahead, and •those in deep trouble. The US health care system is in trouble, and rather than single reforms, it needs and is getting reengineered. •7 days to 4 hours # of deals increased a 100 fold JAMA - Feb 2013, Ari Hoffman, MD, Ezekiel J. Emanuel, MD, PhD
  5. 5. © 2014 IBM Corporation 5 Smarter Care Population Health System Integrator Patient Experience The System Integrator Creates a partnership across the medical neighborhood Drives PCMH primary care redesign Offers a utility for population health and financial management Per Capita Cost Public Health Away from Episode of Care to Management of Population Hospital Community Health
  6. 6. © 2014 IBM Corporation 6 Smarter Care 36.3% Drop in hospital days 32.2% Drop in ER use 12.8% Increase Chronic Medication use -15.6% Total cost 10.5% Drop Inpatient specialty care costs 18.9% Ancillary costs down 15.0% Outpatient specialty down Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US - PCPCC Oct 2012 Smarter Healthcare
  7. 7. © 2014 IBM Corporation 7 Smarter Care
  8. 8. © 2014 IBM Corporation 8 Smarter Care Rural New York Costs for Medicaid patients dropped from $334 to $266, according to a recent “risk adjusted” analysis. traction/article_5811380c-2ee9-11e3-8548-001a4bcf887a.html
  9. 9. © 2014 IBM Corporation 9 Smarter Care JAMA Article
  10. 10. © 2014 IBM Corporation 10 Smarter Care
  11. 11. © 2014 IBM Corporation 11 Smarter Care 44% reduction in hospital costs 21% reduction in overall medical costs. 160 PCMH practices Pennsylvania from 2009 to 12 Number of patients with poorly controlled diabetes declined by 45% Jeffrey Bendix n3/Medical-Homes-and-Cost-and-Utilization-Among-High-Risk- Patients#sthash.qR8uWb4t.dpuf PCMH Pennsylvania March, 2013 Conclusions: PCMH practices had significantly reduced costs and utilization for the highest risk patients, particularly with respect to inpatient care.
  12. 12. © 2014 IBM Corporation 12 Smarter Care Ogden UT , USA 2012
  13. 13. © 2014 IBM Corporation 13 Smarter Care
  14. 14. © 2014 IBM Corporation 14 Smarter Care MobileFirst Patient Consumer
  15. 15. © 2014 IBM Corporation 15 Smarter Care Today’s Care PCMH Care My patients are those who make appointments to see me Our patients are the population community Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet patient needs with or without visits Care varies by scheduled time and memory or skill of the doctor Care is standardized according to evidence-based guidelines Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care I know I deliver high quality care because I’m well trained We measure our quality and make rapid changes to improve it It’s up to the patient to tell us what happened to them We track tests & consultations, and follow-up after ED & hospital Clinic operations center on meeting the doctor’s needs A multidisciplinary team works at the top of our licenses to serve patients Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
  16. 16. © 2014 IBM Corporation 16 Smarter Care Superb Access to Care Patient Engagement in Care Clinical Information Systems, Registry Care Coordination Team Care Communication Patient Feedback Mobile easy to use and Available Information Defining the Care Centered on Patient
  17. 17. © 2014 IBM Corporation 17 Smarter Care Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement Source: Hudson Valley Initiative
  18. 18. © 2014 IBM Corporation 18 Smarter Care Payment reform requires more than one method, you have dials, adjust them!!! “fee for health” fee for value “fee for outcome” “fee for process” “fee for belonging “fee for service” “fee for satisfaction”
  19. 19. © 2014 IBM Corporation 19 Smarter Care Give me enough medals and I'll win you any war' Napoleon Bonaparte – not just the $Green$ that brings JOY The Science of Rewards, incentives
  20. 20. © 2014 IBM Corporation 20 Smarter Care % Total Healthcare Spend % of Members Those who are well or think they are well Those with chronic illness Those with severe, acute illness or injuries Benefit Redesign - Patient Engagement Different Strategies for Different Healthcare Spend Segments
  21. 21. © 2014 IBM Corporation 21 Smarter Care Public Health Prevention Specialists PCMH 2.0 in Action Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers Care Coordinators Public Health Prevention HEALTH WELLNESS Hospitals PCMH PCMH Health IT Framework Global Information Framework Evaluation Framework Operations A Coordinated Health System 35
  22. 22. © 2014 IBM Corporation 22 Smarter Care Preventive Medicine Medication Refills Acute Care Nursing Test Results Master Builder DOCTOR Source: Southcentral Foundation, Anchorage AK Behavioral Health Case Manager Medical Assistants Chronic Disease Monitoring Practice transformation away from episode of care
  23. 23. © 2014 IBM Corporation 23 Smarter Care Medication Refills Chronic Disease Monitoring Test Results Acute Care Preventive Medicine Point of Care Testing Acute Mental Health Complaint Chronic Disease Compliance Barriers Healthcare Support Team Behavioral Health Medical Assistants Case Manager ProviderClinician Source: Southcentral Foundation, Anchorage AK PCMH Parallel Team Flow Design: the glue is real data, not a doctor’s brain
  24. 24. © 2014 IBM Corporation 24 Smarter Care Healthcare Will Transform Data Driven Every person has a plan Team based Managing a population down to the person .
  25. 25. © 2014 IBM Corporation 25 Smarter Care Three key aspects of PCMH Smarter Care coordination Provide holistic, individualized care Collaborate for better outcomes Orchestrate and integrate across the enterprise and community
  26. 26. © 2014 IBM Corporation 26 Smarter Care 1. Pursue Electronic Patient Management and engagement rather than Electronic Patient Records 2. Bring to bear upon every patient encounter what is known rather than what a particular provider knows. 3. Make it easier to do it right than not to do it at all. 4. Continuous performance improvement. 5. Infuse new knowledge and decision- making tools throughout an organization instantly.
  27. 27. © 2014 IBM Corporation 27 Smarter Care 6. Establish and promote continuity of care with patient education, information and plans of care. 7. Enlist patients as partners and collaborators in their own health improvement. 8. Evaluate the care of patients and populations of patients longitudinally. 9. Audit provider performance based on the Consortium for Physician Performance Improvement Data Sets. 10. Create multiple case-management tools which are integrated in an intuitive and interchangeable fashion giving patients the benefit of expert knowledge about specific conditions while they get the benefit of a global approach to their total health
  28. 28. © 2014 IBM Corporation 28 Smarter Care Practices Features -- - Emphasis on care coordination and system navigation, System Integrator, PCMH role for family physician in integrated system - Big push on population health management - Care teams with PCP + a variety of other professions, e.g., nursing, pharmacy, public health and mental health. Technology Use - Better population health data stemming from centralized data based EHR through integrated system. - Adoption of telemedicine, Establish Primary Care Technology Center (PCTC), a research and training entity, to fuel adoption of efficacious technology in practice, patient engagement tools. Modern, flexible, sophisticated system, developed in partnership with technology providers. -Multi-modal communication w/ patients .
  29. 29. © 2014 IBM Corporation 29 Smarter Care Building a Workforce -- Training in the use of population health management, data management and public health tools - Dual degrees – MD + MBAs, MPHs - .Add’l training in interprofessional collaboration, EHR data usage, and integrated practice management. Research Focus -- Conclusive evidence about system wide quality improvement and cost savings of robust primary care.- Rise of Continuum-Based Research Networks, applied research efforts to improve clinical pathways. - Research builds case for reductions in Total Cost of Care (at system level), research into technologies most inpactful on Triple Aim. - FM becomes trusted source of best practices to meet Triple Aim, .Focus on issues that relate to patients owning their own health through patient experience and engagement research
  30. 30. © 2014 IBM Corporation 30 Smarter Care Collaboration -- - Family medicine’s partnership with payers and the integrated systems, to exchange ideas about how to best deploy family physicians and represent their colleagues’ interests to these systems - Subspecialists – to ensure great working relationships within systems. - Primary care professionals – to achieve the best possible outcomes in service of Triple Aim. Payers, particularly CMS – to ensure success of alternative payment pilots.- Primary Care Nurse Practitioners (to work together in pursuit of expanded role of Primary Care, Technology manufacturers) to provide advice on how to improve technology in use by FPs, Key Investments -- Curricular overhaul and research effort to prepare residents for work in integrated systems, tools for data being made into actionable information in population management, advance clinical decision support
  31. 31. © 2014 IBM Corporation 31 Smarter Care Thank you
  32. 32. © 2014 IBM Corporation 32 Smarter Care A comprehensive approach helps reduce costs while improving care Apply new insights from interactions and outcomes to enable continuous transformation LEARNING Identify and influence individuals and populations, and recognize intervention opportunities INTERVENTION COORDINATION Deliver care and monitor progress across clinical and social requirements COLLABORATION Assess and engage individuals and stakeholders to drive individualized care plans Drive evidence-based and standardized care planning KNOWLEDGE WELLNESS 3
  33. 33. © 2014 IBM Corporation 33 Smarter Care
  34. 34. © 2014 IBM Corporation 34 Smarter Care 3
  35. 35. © 2014 IBM Corporation 35 Smarter Care Trademarks and notes © IBM Corporation 2014 • IBM, the IBM logo,, and Cúram are trademarks or registered trademarks of International Business Machines Corporation in the United States, other countries, or both. If these and other IBM trademarked terms are marked on their first occurrence in this information with the appropriate symbol (® or ™), these symbols indicate U.S. registered or common law trademarks owned by IBM at the time this information was published. Such trademarks may also be registered or common law trademarks in other countries. A current list of IBM trademarks is available on the Web at “Copyright and trademark information” at • Other company, product, and service names may be trademarks or service marks of others. • References in this publication to IBM products or services do not imply that IBM intends to make them available in all countries in which IBM operates.