Medical Home Model: Patient Centered Care


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  • Rob Welcome & introductions Outline of the day: Rob – pilot/results Claire & Barbara – leadership and team development challenges Michael – future work Open mic discussion at conclusion of presentation. This is a time to share your thoughts on the work that has been done, changes that have been made, and work that is being done for the future. Do you have questions? Comments? Feedback?
  • Rob In the last decade, policy makers and payers have agreed that to control costs, improve quality, and improve outcomes, need to reinvigorate primary care Indeed its been on the decline for many years – neglect, poor funding, and lack of recognition Here are the issues as I see them Attention has rightly focused back on primary care as part of the answer My worry is that the expectations are too great – solve all the problems, and in short order.
  • Rob READ GH Made decision to invest in one clinic as a prototype Redesign care at pilot site, test it, evaluate it for internal purposes, use learnings to guide redesign at other clinics.
  • Rob The model’s premise is that good outcomes at the bottom of the model (better health status and patient satisfaction) result from productive interactions. To have productive interactions, the practice must be redesigned in four areas (shown in the middle): self-management support (how we help patients address their conditions), delivery system design (who’s on the primary care team and in what ways they interact), decision support (what is the best care and to make it happen every time) c linical information systems (how do we capture and use critical information for clinical care). Some aspects of larger healthcare organizations influence clinical care. The health system itself exists in a larger community . Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is the most visible part of care to the patient, followed by delivery system design. They may be unaware of the other components.
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  • Michael Organization hasn’t had any experience with expanding its footprint in 15 years. An opportunity to provide the means to achieve the organization’s ambitious strategic goals to grow the group practice…and perhaps in new ways (micro clinics; PC + medical sub-specialties) Current lead time to open new medical center (from funding to doors open) = 40 months Our challenge is to open new facilities within 6 – 12 months
  • Michael Opportunity to bring a different level of patient care to our member Continue to ask staff to be co-designers Every member of the care team will have a means to be involved in shaping how the new buildings look and feel
  • Michael First iteration of medical home we knew we weren’t going to solve all the problems in the universe. We have an opportunity now to do what we didn’t do; from focus on content of care to patient experience. It’s time to be disruptive and innovative again, to be able to thrive as a business, and to deliver truly patient-centered care. We now have the means and the method…and the opportunity awaits! This will build on and expand FLI principles and our capabilities: Value is defined by our patients Everyone is engaged and empowered Improvement is part of your everyday work Making the care and service to our patients safer, simpler, and better. Currently about 1 million PC visits per year, so lots of opportunity to deliver a different experience. It’s time to innovate and be ahead of the competition to thrive.
  • Michael We can create more value for our patients: We have state of the art technology to service a line of people. Currently 90% of pharmacy patients are served within 10 minutes of pulling a number; we have great capabilities, but we can do better. RED figured out a way to not make patients wait , so the opportunity here is what to do with all the unused space. How to get to Patient Centered Facility Design? Take patient-centered attributes and care delivery value stream and apply to space planning.
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  • Medical Home Model: Patient Centered Care

    1. 1. Michael Erikson, MSW , vice president, Primary Care Services Robert Reid MD, PhD, MPH , associate medical director, Health Services Research & Knowledge Translation Barbara Trehearne PhD, RN , v ice president, Clinical Excellence, Quality, and Nursing Practice Claire Trescott, MD, medical director, Primary Care Services     The Medical Home Model: Patient Centered Care
    2. 2. The Burning Platform of Primary Care <ul><li>Access to primary care difficult for many, particularly disadvantaged. </li></ul><ul><li>Quality of remains mediocre with many gaps. </li></ul><ul><li>Payment systems are antiquated. Many functions are unrewarded. </li></ul><ul><li>Evidence-base has become unmanageable for individual physicians. </li></ul><ul><li>Primary care is an unattractive career choice. Burnout common . </li></ul>
    3. 3. Medical Home Design Principles The relationship between the clinician & patient is at our core. The entire delivery system will reorient 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. ✔ ✔ ✔ ✔ ✔
    4. 4. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Community Resources & Policies Health Care Organization Improved Outcomes The Chronic Care Model (CCM) (Wagner EH et al, Managed Care Quarterly, 1999.7(3) 56-66)
    5. 5. Medical Home: Change Components <ul><li>Calls redirected to care teams </li></ul><ul><li>Secure e-mail </li></ul><ul><li>Phone encounters </li></ul><ul><li>Pre-visit chart review </li></ul><ul><li>Collaborative care plans </li></ul><ul><li>EHR best practice alerts </li></ul><ul><li>EHR prevention reminders </li></ul><ul><li>Defined team roles </li></ul>Point-of-care changes <ul><li>ED & urgent care visits </li></ul><ul><li>Hospital discharges </li></ul><ul><li>Quality deficiency reports </li></ul><ul><li>e-health risk assessment </li></ul><ul><li>Birthday reminder letters </li></ul><ul><li>Medication management </li></ul><ul><li>New patients </li></ul>Patient-centered outreach <ul><li>Team huddles </li></ul><ul><li>Visual display systems </li></ul><ul><li>PDCA improvement cycles </li></ul><ul><li>Salary only MD compensation </li></ul>Management & payment PCMH Model
    6. 6. Group Health Medical Home Staffing Model 100% 1.0 FTE Pharmacist (no change) 5.6 FTE MA 65% 2.0 FTE LPN (no change) 1.2 FTE RN 70% 1.5 FTE PA/NP 17% 5.6 FTE Physician (panels 2500 to 1800) Increased Staffing (per 10,000 enrollees)
    7. 7. Medical Home 1 & 2 Year Pilot Outcomes Group Health Research Institute QUALITY (HEDIS) Year 1: Rate of rise, 2x that of control clinics Year 2: Rate of rise continued to be 20-30% greater in 3 of 4 composites PATIENT/STAFF SATISFACTION Year 1: Patient satisfaction – 5% increase in patient activation/goal setting; Practioners - *substantially less burn-out with significantly reduced emotional exhaustion & depersonalization Year 2: Scores continued to improve at Medical Home; controls were slightly worse ED/UC UTILIZATION Year 1: 29% fewer ER visits, 11% fewer preventable hospitalizations, 6% fewer but longer in-person visits Year 2: Significant changes persisted COST Year 1: Cost is neutral Year 2: Overall patient care costs lower at Medical Home (~$10 PMPM) Year 1 Year 2
    8. 8. Challenges Overcome
    9. 9. <ul><li>All Work Processes are designed by staff who do the work </li></ul><ul><li>Representatives from diverse clinics contribute to design </li></ul><ul><li>Initial designs will be flawed, aim for 50% improvement </li></ul><ul><li>All feedback from frontline staff will be recorded and used to improve processes </li></ul>Essential Leadership Concepts
    10. 10. Key Elements: Management System Links Business plan to front line work Alternative to “execution by wishful thinking” Shows Performance Gaps Multiple Levels Driver of Change Reduce Waste Improve Quality Patients Point of View Accountability Lean Management System Metrics and Visual Displays Value Stream Redesign
    11. 11. Our “Secret Sauce” for Spreading Standard Work <ul><li>MANAGEMENT BELONGS IN THE CLINICS </li></ul><ul><li>Leaders must understand all standard work </li></ul><ul><li>Leaders round on all standard work daily or weekly </li></ul><ul><li>Processes and outcomes are visible in the clinic </li></ul><ul><li>Where we struggled with implementation it was ALWAYS because of leadership problems </li></ul><ul><li>Work in the clinics is linked to visible data at all levels of management </li></ul>
    12. 12. Current Innovation: Frontline Improvement Initiative <ul><li>Moving from Adaptive Leadership to an Adaptive Workforce </li></ul><ul><li>Designing for a world of continuous change </li></ul><ul><li>Using Lean principles to do structured changes in everyday processes </li></ul>
    13. 13. Building Teams <ul><li>Probably our most difficult leadership challenge </li></ul><ul><li>Co-location does not guarantee teamwork </li></ul><ul><li>Physician’s not necessarily trained to work in teams </li></ul><ul><li>Huddles essential and continue to offer opportunities </li></ul><ul><li>Nursing changes challenging </li></ul><ul><li>Visible Patient Care Boards are effective </li></ul>
    14. 14. Nursing Boards
    15. 15. Medical Home: Role of Nursing <ul><li>Outpatients require higher level of care </li></ul><ul><li>Increased complexity of care requires higher skill for coordination and chronic disease management </li></ul><ul><li>Skilled RNs can effectively manage chronic illness in partnership with a well developed interdisciplinary team </li></ul><ul><li>Team RNs and Complex Case Managers focus on self management support & increasing motivation to improve adherence to care/medications </li></ul><ul><li>Team based RNs can assess broad spectrum of needs, partner with patient and PCP, develop plan of action, coordinate resources </li></ul>
    16. 16. Nursing Challenges <ul><li>Capacity for managing both acute and chronic populations </li></ul><ul><li>Need to rethink skill development; what do nurses need to know </li></ul><ul><li>Role changes from ‘tradition’ outpatient to patient centered, focus on self management, coordination of care </li></ul>
    17. 17. Transition to the Future Medical Home Model
    18. 18. Rethinking Medical Centers Tier 3: Medical Sub-specialties Tier 2: Eye Care, Occ Health, PT Tier 1: PC, Pharmacy, Lab, Radiology TIER 1 TIER 2 TIER 3
    19. 19. Transformational Thinking See what’s not there Reframe Move Think about nature Journalistic Six Word Association Change your lens
    20. 20. Next Evolution of Our Clinical Transformation Patient-Centered Medical Home <ul><li>CSS Honors </li></ul><ul><li>2010 Achievements </li></ul><ul><li>PDP </li></ul><ul><li>Virtual Visits </li></ul><ul><li>Call Management </li></ul>
    21. 21. Care & Facility Redesign Opportunities
    22. 22. What’s Next for Medical Home? Integrated Care & Facility Design – Using 3P <ul><li>As an extension to Group Health's medical home practice redesign, we are looking to the next stage to: </li></ul><ul><ul><li>Redesign how the staff optimally interacted with each other and their patients </li></ul></ul><ul><ul><li>Redesign the staffing. Redesign the physical work environment to further optimize our clinical work and patient’s experience </li></ul></ul><ul><li>The brick and mortar solutions will focus on: </li></ul><ul><ul><li>Standardization of rooms, materials, furniture, equipment </li></ul></ul><ul><ul><li>Modular walls and furniture </li></ul></ul><ul><ul><li>Sustainability with a focus on mechanical systems </li></ul></ul><ul><ul><li>Evidence based design solutions </li></ul></ul><ul><ul><li>Integrated Project Delivery Agreements </li></ul></ul>
    23. 23. Integrated Care & Facility Design – Using 3P <ul><li>The brick and mortar solutions will focus on: </li></ul><ul><ul><li>Increasingly more care is virtual </li></ul></ul><ul><ul><ul><li>Phone </li></ul></ul></ul><ul><ul><ul><li>E-visits </li></ul></ul></ul><ul><ul><ul><li>Consultations between medical-surgical specialties </li></ul></ul></ul><ul><ul><li>Co-design all processes that patients use or touch within a visit </li></ul></ul><ul><ul><ul><li>Check-in – business function </li></ul></ul></ul><ul><ul><ul><li>Clinical </li></ul></ul></ul><ul><ul><ul><li>Ancillary </li></ul></ul></ul><ul><ul><li>Design those processes around the patient: be patient centered </li></ul></ul><ul><ul><ul><li>Example </li></ul></ul></ul><ul><ul><ul><li>Bring services to patients </li></ul></ul></ul><ul><ul><ul><li>Reduce/eliminate waiting </li></ul></ul></ul><ul><ul><ul><li>Can waiting rooms become unnecessary? </li></ul></ul></ul><ul><ul><li>Consider & design all material supply chains to reduce inventory and turn rates </li></ul></ul><ul><ul><li>Design in flexibility, quality while reducing overall facilities costs </li></ul></ul><ul><ul><li>Partner with architects, builders differently </li></ul></ul>What’s Next for Medical Home?