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PCMH STFM 2011<br />Paul Grundy, MD, MPH, FACOEM, FACPM IBM Director Healthcare TransformationPresident Patient Centered Primary Care Collaborative<br />Paul Grundy MD, MPH <br />IBM International Director Healthcare Transformation<br />Trip to Denmark July 10 2009 <br />

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Who was the <br />Shooter’s Doctor? <br />Population management<br />Accountability <br />

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You Tube Video<br />

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Why Innovate Affordability<br />$30,000<br />+166%<br />$25,000<br />$20,000<br />$15,000<br />+118%<br />$10,000<br />$4,918<br />$5,000<br />$0<br />2001<br />2009<br />2019<br /> - Employee Payroll Contributions<br />- Employer Cost<br />- Employee Out of Pocket Expenses<br />a<br />The Elephant in the room<br />$28,530<br />Costs continue their upward climb…<br />…with employers still picking up much of the tab…<br />$10,743<br />

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The Cause? Mostly due to unregulated fee-for-service payments and an over reliance on rescue/specialty care. This is stark evidence that the U.S. health care Industry has been failing us for years “Commonly cited causes for the nation's poor performance are not to blame - it is the failure of the deliver system!!”<br />You the AHC’s - Unaccountable Care Organizations PART of this problem <br />* Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010<br />

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Health care is a business issue, not a benefits issue<br />

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3° Care<br />2° Care<br />What’s wrong with this picture?<br />1° Care<br />Every country starts at the base of the pyramid with primary care, and they work their way up until the money runs out.<br />… “We start at the top of the pyramid, and we work our way down until the money runs out…And so we have to change the pyramid. We have to start at the base.”<br />3° Care<br />2° Care<br />1° Care<br />

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Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!!<br />Unaccountable care, lack of organization, DO NOT GO THERE ALONE !! <br />Be wise when you pay for care, KNOW WHAT YOU BUY!!<br />

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Coordination -- we do NOT know how to play as a team<br />“ We don't have a health care delivery system in this country. We have an expensive plethora of uncoordinated, unlinked, micro systems, each performing in ways that too often create sub-optimal performance, both for the overall health care infrastructure and for individual patients." George Halvorson, from “Healthcare Reform Now<br />Saudi Arabia’s King Abdulaziz traveled to the U.S. to receive treatment slipped disc<br />

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“We do heart surgery more often than anyone, but we need to, because patients are not given the kind of coordinated primary care that would prevent chronic heart disease from becoming acute.”<br /> George Halvorson (CEO Kaiser) from “Healthcare Reform Now”<br />

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The most important tool - mind of the Family <br />Physician focused on two things, relationship, <br />Difficult diagnostic dilemmas <br />A long-term comprehensive relationship with your Personal Physician empowered with the right tools and linked to your care team can result in better overall family health…<br />

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The Joint Principles: Patient Centered Medical Home<br /><ul><li>Personal physician - each patient has an ongoing relationship with a personal physiciantrained to provide first contact, and continuous and comprehensive care

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Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients

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Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or arranging care with other qualified professionals

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Care is coordinated and integrated across all elements of the complex healthcare community- coordination is enabled by registries, information technology, and health information exchanges

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Quality and safety are hallmarks of the medical home- </li></ul> Evidence-based medicine and clinical decision-support tools guide decision-making; Physicians in the practice accept accountability voluntary engagement in performance measurement and improvement<br />Enhanced access to care is available - systems such as open scheduling, expanded hours, and new communication paths between patients, their personal physician, and practice staff are used <br /><ul><li>Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home- providers and employers work together to achieve payment reform </li></ul>12<br />

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The Quadruple AimReadiness, Experience of Care, Population Health, Cost<br />Per Capita Cost<br />Population<br />Health<br />The System Integrator <br />Creates a partnership across the medical neighborhood <br />Drives PCMH primary care redesign<br />Offers a utility for population health and financial management<br />System Integrator<br />Patient<br />Experience<br />Productivity <br />

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<ul><li>You need a Captain for the ship

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You need a place of command and control

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You need a horizontal platform from which to launch vertical weapon systems

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You need somewhere and someone to hold accountable</li></li></ul><li>If you scan the world for value based healthcare, you will find a common element: a relationship-based team with a project manager!<br />A comprehensivist that can command and control in an accountable system. <br />So simple!<br />So much!<br />

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Team-Based <br />HealthcareDelivery<br />Population<br />Health <br />Access to Care<br />Patient<br />is the centerof theMedical Home<br />Advanced IT Systems<br />Patient-Centered Care<br />Decision Support Tools<br />Refocused Medical Training<br />Patient & Physician Feedback<br />Enhancing Health and the Patient Experience<br />Medical Home Model<br />Model adapted from theNNMC Medical Home<br />

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Defining the Care<br />Superb Access to Care<br />Team Care<br />Patient Engagement in Care<br />Patient Feedback<br />Clinical Information Systems<br />Publically Available Information<br />Care Coordination<br />

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Smarter Healthcare…<br />36.3% Drop in hospital days<br />32.2% Drop in ER use <br />9.6% Total cost <br />10.5% Inpatient specialty care costs are down<br />18.9% Ancillary costs down <br />15.0% Outpatient specialty down<br />Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US, K. Grumbach & P. Grundy, November 16th 2010 <br />

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OPM $39 Billion Book with Accountable Care <br /><ul><li>24-7 clinician phone response

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Provide open scheduling.

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Provide care management and coordination by specially-trained team members.

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Use an EHR with decision support.

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Use CPOE for all orders, test tracking, and follow-up.

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Medication reconciliation for every visit.

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Prescription drug decision support.

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Implement e-prescribing.

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Pre-visit planning and after-visit follow-up for care management.

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Offer patient self-management support.

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Provide a visit summary to the patient following each visit.

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Maintain a summary-of-care record for patient transitions.

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Email consultations.

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Telephone consultations.

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The development of care plans.

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Performance outcome </li></ul> measures.<br />

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Trends this week <br />Highmark Inc. Patient-Centered Medical Home Program Designed to Improve Coordination <br />Adirondack Region Medical Home Pilot <br />Somava Stout, MD, Vice President for Patient-Centered Medical Home Development at Cambridge Health Alliance (CHA),<br />Horizon PCMH NJ (BCBS NJ) <br />Army Screaming eagle PCMH <br />

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Corporate Concierge PCMH The private clinic is for the employees and Families on or near site <br />From 10.2% to 23.7% of company care <br />OneAmerica to Open PCMH Wellness Clinic<br />Perdue opens 15th PCMH<br />Central Louisiana Family Health and Wellness Center. Martin Companies and Gilchrist Construction Co and 23 other companies <br />

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PCMH in Action <br />Vermont “Blueprint” model <br />A Coordinated <br />Health System<br />Hospitals<br />Community Care Team<br />Nurse Coordinator<br />Social Workers<br />Dieticians<br />Community Health Workers<br />Care Coordinators<br />Public Health Prevention<br />HEALTH WELLNESS<br />PCMH<br />Health IT <br />Framework<br />Specialists<br />Global Information Framework<br />PCMH<br />Evaluation <br />Framework<br />Public Health Prevention<br />Operations<br />

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Vermont Financial Impact<br />Vermont Financial Impact<br />

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Sharp Community Medical Group: Care Transformation Model<br />Accountable Community Accountable Care Organization<br />Enterprise Level Activities<br />Patient-Centered Medical Home<br />Patient<br />

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PCMH is non-political – the right POV for delivery transformation <br />“We never abandoned advocating new<br />Models of care. We’ve long pushed folks<br />to realize that Delivery reform is the key.”<br />The patient-centered medical home is<br />core.<br />“We included the attached chapter on PCMH in our book. and have a new publication on ACOs coming out in January.”<br />

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OR? <br />…Requires a Smarter Healthcare Workforce<br />Where do you train the MHS Workforce? <br />

48.

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Payment reform requires more than one method, you have dials, adjust them!!!<br />fee for health”<br />“fee for outcome”<br />“fee for process”<br />“fee for belonging<br />“fee for service” <br />“fee for satisfaction”<br />

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Technology Enables the Progression to Clinical Integration and Accountable Care <br />“Accountable Care Enablement”<br />“Clinical Integration Enablement”<br />Risk , UM & Care Management <br />Financial & Utilization Analytics<br />Financial & Utilization Analytics<br />Care Management<br />Care Management <br />“Meaningful Use Enablement”<br />Patient Health Record<br />Patient Health Record<br />Clinical <br />Quality Metrics<br />Clinical <br />Quality Metrics<br />Clinical <br />Quality Metrics<br />Registry &<br />Population Mgmt<br />Registry &<br />Population Mgmt<br />Registry &<br />Population Mgmt<br />EMR / PMS<br />EMR / PMS<br />EMR / PMS<br /><ul><li>Team based care and workflow

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Enable Patients

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Manage populations

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Manage performance

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Digitization & Interoperability

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Identify gaps in care

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Price / manage risk

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Create a sustainable economic model</li></li></ul><li>Recommendations<br /><ul><li>Build the foundation, the horizontal platform, a place of accountability - PCMH

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Really engage your patients find out what they need and become very patient centered

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Integrate value base purchasing with PCMH in your plan designee (understand what the buyer wants)

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Stop teaching the past you are in a world of Data, teams, actionable information

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Integrate Health and Sick care

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GIVE US LEADERSHIP - SHOW US THE WAY!</li>