The medical home

1. The Medical Home
A 26 year experience
Internal Medicine Northwest
1984-2010
David R Muňoz, MD, MPH, FACP, FABQAURP, CMD

2. The Medical Home
• Internal Medicine North West (IMNW) was a
unique practice pioneering most of the
concepts embodied in the current definition
of the Medical Home, which provided care for
complex internal medicine patients, which
operated for 26 years between 1984 and
2010.

3. DEMOGRAPHICS
•
GENDER COUNT
MALES 9682
FEMALES 17275
TOTAL 26957

4. The Medical Home Model
2007 Joint Definition
• Personal physician: "each patient has an ongoing relationship with a
personal physician trained to provide first contact, continuous and
comprehensive care."
• 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."
• Whole person orientation: "the personal physician is responsible for
providing for all the patient’s health care needs or taking responsibility for
appropriately arranging care with other qualified professionals."
• Care is coordinated and/or integrated: Care is coordinated and/or
integrated between complex health care systems, for example across
specialists, hospitals, home health agencies, and nursing homes, and also
includes the patient’s loved ones and community-based services. This goal
can be attained though the utilization of registries, health information
technology and exchanges, ensuring patients receive culturally and
linguistically appropriate care.[9]

5. Quality and Safety
– Partnerships between the patient, physicians and their family
are an integral part of the medical home. Practices are
encouraged to advocate for their patients and provide
compassionate quality, patient-centered care
– Guide decision making based on evidence based medicine and
with the use of decision-support tools
– Physician’s voluntary engagement in performance
measurements to continuously gauge quality improvement
– Patients are involved in decision making and provide feedback
to determine if their expectations are met
– Utilization of informational technology to ensure optimum
patient care, performance measurement, patient education, and
enhanced communication
– At the practice level, patients and their families participate in
quality improvement activities.[9]

6. Enhanced access
• Care is available through open scheduling and
extended hours and new options for patient
services.[9][24]
• This may include telemetric monitoring
• Includes Point of Service (POS) testing for
rapid results and detailed instructions

7. Requires Appropriate Funding
• Payment must "appropriately recognize the added
value provided to patients who have a patient-
centered medical home."
• Payment should reflect the time physician and non-
physician staff spend doing patient-centered care
management work outside the face-to-face visit
• Services involved with coordination of care should be
paid for
• It should support measurement of quality and
efficiency with the use and adoption of health
information technology.[25]

8. Appropriate Funding Continued
– Enhanced communication should be supported
– It should value the time physicians spend using
technology for the monitoring of clinical data
– Payments for care management services should
not result in deduction in payments for face-to-
face service
– Payment "should recognize case mix differences in
the patient population being treated within the
practice"

9. Appropriate Funding Continued
– It should allow physicians to share in the savings
from reduced hospitalizations
– It should allow for additional compensation for
achieving measurable and continuous quality
improvements

10. How I came to be here

11. Transistions
• IMNW determined in 2009 that in order to continue
to deliver its mission to deliver comprehensive,
competent, coordinated care for complex older
adults, it needed to integrate with a larger
organization which could provide the basis for an
Accountable Care Organization.
• We then sought out and executed the transition to
the Franciscan Medical Group, a part of Franciscan
Health Services, Catholic Health Initiatives.

12. Personell
• IMNW was comprised of 9 physicians all Board
Certified Internists including 4 hospitalists, 3
rheumatologists, 3 geriatricians and 2
hospice/palliative care physicians. Some
physicians were multi-board certified. In addition
2 physicians were Board Certified Quality
Assurance Utilization Review Medicine Diplomats
and AMDA Certified Medical Directors
• IMNW also had 2 nurse practitioners, one
Geriatric and one Adult Medicine as well as a
Masters trained Diabetic Educator

13. Legacy
• IMNW provided care in the outpatient,
inpatient and skilled nursing facility settings
for an active patient population of about
7,000 patients and over the course of its
history IMNW served 25,000+ patients.
• IMNW operated the first Medicare Approved
Comprehensive Outpatient Rehabilitation
Facility (CORF) in Washington State 1986-1991

14. Inpatient Services
– IMNW provided inpatient services within the
Franciscan Health System at St Joseph, St Clare, St
Francis 1984-2009
– IMNW provided inpatient services within the
MultiCare Health System at Tacoma General and
Allenmore Hospitals 1984-2009
– Important because 60% of all our patients used
both systems of care

15. Long Term Care
– IMNW provided Medical Direction and SNF care at:
• Tacoma Lutheran Retirement Community
• Franciscan Health Care Center
• Franke Tobey Jones Home
• Belair Rehab & Ventilator Care Center
• Heartwood
• University Place Care Center
– IMNW provided SNF care at an additional 10 SNF
facilities and 5 Assisted Living Facilities

16. Extended Care Services
– IMNW provided care in coordination with
Franciscan, MultiCare and Good Samaritan
Hospices
– IMNW worked with more than 30 community and
home health agencies
– IMNW provided chronic wound care at Franciscan
Wound Care Center

17. Patient/Family Centered
• IMNW worked closely with its patients and
their families
• IMNW experienced up to 5 generations of
care for family members
• IMNW provided care for many generations
who successively experienced aging
• IMNW’s longest surviving marriage William &
Helen Bookwalter was 77 years

18. Point of Service Delivery
• IMNW pioneered the use of point of service
(POS) testing including
– Hematocrits
– HBA1C
– INR
– LFT’s
– Lipid panels

19. Cardiovascular Monitoring
• IMNW pioneered the use of extended in home
monitoring in a clinical trails with CardioCare
for patients with Diabetes and CHF
• Office based use of echocardiography and
vascular studies in partnership with
Cardiodynamics for its large populations with
congestive heart failure, diabetes and
metabolic syndrome

20. Diabetic Monitoring
• IMNW provided 24 hour glucose recording
• IMNW provided Diabetic Education with our
own Masters Prepared Certified Diabetic
Educator
• IMNW provided POS HBA1C and Lipid
Monitoring
• IMNW provided comprehensive diabetic
wound care

21. Clinical Research Department
performed 80 clinical research trials during a 15 year timeframe.
– Clinical studies of Alzheimer’s Disease (SmithKline Beecham;
Somerset; Parke-Davis; Novartis; Bayer and Zeneca)
– Clinical studies of Acute Ischemic CVA (Lorex; Bristol, Meyer, Squibb;
ICOS)
– · Clinical studies of Diabetes (Miles; Eli Lily)
– · Clinical studies of Decubitus Ulcers (CIBA; Ethicon; Johnson &
Johnson; Daiichi)
– · Clinical studies of infection, Pneumonia (Upjohn); Cellulitis, (Tap) and
Urinary Tract Infections
– · Clinical studies in Hypertension (Merck; ICI)
– · Clinical studies in Congestive Heart Failure (ICI; Eli Lilly)
– · Clinical studies in Musculoskeletal Impairment (Merck; Purdue)
– · Clinical studies in Urinary Incontinence (Lilly; Alza)

22. Electronic Health EHR & E-Rx
• IMNW maintained an electronic health care
record throughout its 26 year existence, which is
being abstracted into a comprehensive research
data base.
• IMNW also pioneered the use of electronic
prescriptions, with an early patent on a form of
telephone/fax communication of our prescription
data base” 7,426,476 System and method for
automated prescription management

23. Clinical Analytics
• IMNW pioneered the use of Clinical Analytics
using its substantial data base and those of
PacLab & Laboratories Northwest to manage
its patients with chronic disease
• Models were applied in both outpatient and
SNF populations

24. • IMNW also operated for 5 years the first
Comprehensive Outpatient Rehabilitation Center
in Washington State
– provided outpatient/home evaluation of appropriate
Medicare patients
– Offered comprehensive physical, occupational,
speech and respiratory therapy, social services and
clinical psychology. The reimbursement mechanism
was lesser of cost or charges. (It ceased this operation
in 1991 after Medicare determined that CMS did not
have enough accountants to open the 60 page Cost
Report and settle the $56,000 debt that was owed to
IMNW for 2 years at no interest.)

25. Financial Challenges
• IMNW was 60% Medicare and 18% Medicaid
based
• Successfully weathered 2 Federal Government
shutdowns, the worse of which last from
10/27/1986 – 2/02/1987 during which it received
no Medicare or Medicaid Funds
• Experienced 5 Washington State Government
shutdowns resulting in no Medicaid payments for
up to 3 months over the course of its 26 year
history

26. The IMNW Experience
• A $ 25,000 payment for E-prescribing was
received 8 months after the close of the
calendar year and well over 1 year later
• No payment was received for EHR which we in
fact maintained throughout our history
• IMNW suffered grievous financial adversity
through repeated Federal and State budgetary
mismanagement

27. WE ALL BECOME SOMEONE WE’VE NEVER BEEN BEFORE AND THEN SPEND THE
NEXT PHASE OF OUR LIVES COMING TO GRIPS WITH IT
(1951 MGTD, which I purchased for $ 350 when I was 16, rebuilt it in high school,
restored it in 2007 and still drive it)