HIV and Primary Care Transformation baltimore 5 21


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  • Steve: It is going to help us to tailor our presentation by getting some demographic information on you and your practice setting. We have two questions
  • There are many ways to tell a story. In medicine we like these kind of picture, a bar graph with data points, but there are many ways to represent reality. This represents a picture of an unsustainable health care system one that is undermining the economy, So if you had to choose a picture of what this represents, What would it be, a more graphical image to represent this reality, the picture created by this data – what would it be?
  • This graph compares our costs to other industrial countries. This is per capita spending, almost twice what other countries spend. Maybe we are a rich country so that is ok but then the percent of GDP should be the same – iit isn’t again almost twice what other similar countries spend.
  • This adds up to 18 hours. Yikes. That doesn’t include acute care: like when you have the flu, a broken bone, etc. Or lunch.
  • Back in 2009 MichaelSaag wrote this in a beautiful article in the AIDS reader We have built many of the components of a Medical Home. Easy to say – oh yes, we do that, and we do that. We need to be proud of the good work we do. Can we do better? Do we have the components of a house, to extend the metaphor, without the fitting together to make a home? One of the issues we have struggled with in developing the resource center is the balance between supporting transformation of your practices along the lines of the MH vs, the support needed to certify as a PCMH. What I would like you to do for the next 20 minutes is to focus on transformation of your practice, identifying area for improvement
  • So lets take the change concepts from Ed Wagner and compare them side by side with requirements of RWCA grantees
  • Our building blocks to high performing primary care were developed as a roadmap to guide practices during transformation. Transforming to a primary care medical home requires more than checking boxes and capturing screen shots. After over 20 unique site visits to high performing practices in the United States, we saw strikingly similar practices that we were able to identify through data collection, observations, and interviews with leaders, clinicians, pharmacists, and staff including nurses, medical assistants, and clerks. Our analysis revealed recurring themes - structures, systems and practices that were shared across sites. It is from these shared practices that we developed the building blocks of high performing care.
  • This is a busy slide and not meant to be read , I am using it to make a point about medical home concepts– I have listed the key concepts for the PCMH from several sources. The first are the Change Concepts by Ed Wagner, The second column is the building block identified in Tom Bodenheimer’s article and the third
  • HIV and Primary Care Transformation baltimore 5 21

    1. 1. HIV and Primary Care Transformation: RWCA and the PCMH Steve Bromer, MD Department of Family and Community Medicine UCSF
    2. 2. Goals  Why does the US healthcare system need the PCMH?  Why should RWCA clinics transform into PCMHs?  What is the PCMH model and how close are RWCA clinics to it?
    3. 3. ARS: What role do you play in your clinic?  Provider (Physician or Mid-level)  Medical Assistant  Front Office  Administrator  RN  Social Worker  Pharmacist  Other
    4. 4. ARS: My practice setting  Primary Care Practice with HIV Care referred out  Primary care practice with integrated HIV program  HIV Specialty Practice with integrated primary care  HIV Specialty Practice with Primary Care referred out
    5. 5. ARS: Choose the reason A. To learn more about the Patient Centered Medical Home (PCMH) as a way to transform our practice B. To learn more about the details of becoming accredited/recognized as a PCMH C. My boss made me come and Baltimore is a cool city D. To learn about how concepts from the PCMH apply to multiply diagnosed populations
    6. 6. ARS: Choose the statement you agree with most:  HIV patients need excellent HIV specialty care and primary care is not as important for good outcomes  HIV patients need excellent primary care and the HIV specialty care is not as important for good outcomes  Both HIV Specialty care and primary care are important for good outcomes  With today’s medications, HIV patients will do well regardless of the quality of their healthcare
    7. 7. Mortality Amenable to Health Care Deaths per 100,000 population* 1997/98 150 2002/03 130 116 109 99 100 76 81 88 84 89 89 97 71 71 74 74 77 80 82 84 93 96 128 115 113 97 88 50 65 90 115 106 134 82 84 101 103 103 104 Fr an ce Ja p Au an st ra lia Sp ai n Ita Ca ly na d No a Ne r th way er la n Sw d s ed e Gr n ee c Au e s Ge tria rm an y Fi Ne n w la nd Ze al De and Un nm ite d Ki ark ng do m Ire la Po n d Un r ite tug a d St l at es 0 * Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008. 110
    8. 8. Abundant research evidence indicates that health systems and regions with a strong foundation of primary care have:      Better population health outcomes Better quality of care More preventive care Lower costs More equitable care and mitigation of health disparities
    9. 9. Primary Care Strength and Premature Mortality in 18 OECD Countries 10000 PYLL Low PC Countries* 5000 High PC Countries* 0 1970 1980 Year 1990 2000 *Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R 2(within)=0.77. Source: Macinko et al, Health Serv Res 2003; 38:831-65.
    10. 10. Source: Baicker & Chandra, Health Affairs, April 7, 2004
    11. 11. Source: Baicker & Chandra, Health Affairs, April 7, 2004
    12. 12. A Functional Definition of Primary Care: Barbara Starfield Framework first Contact Comprehensive Continuity Coordination
    13. 13. But the Primary Care Foundation in the US is Crumbling  Plummeting numbers of new physicians entering primary care and burnout among PCPs  Growing problems of access to primary care and “medical homelessness”  Dysfunctional systems that are not delivering the goods in primary care
    14. 14. ARS: Approximately what percentage of adults report difficulty getting a prompt appointment, phone advice, or night/weekend care without going to the ER?  10%  25%  50%  75%  90%
    15. 15. ARS: What is the average time before patients are interrupted when making initial statements to their primary care physician?      2 seconds 23 seconds 58 seconds 98 seconds 120 seconds
    16. 16. ARS: What percentage of patients leave the office visit without understanding what their physician said?  10%  25%  50%  75%  90%
    17. 17. Poor clinician/patient relationships  73% of adults surveyed reported difficulty getting a prompt appointment, phone advice, or night/weekend care without going to the ER. Public views on of US health system organization, Commonwealth Fund, 2008  23 seconds: Average time before patients were interrupted when making initial statement of their problem to their primary care physician. Marvel et al. JAMA 1999;281:283  50% of patients leave the office visit without understanding what their physician said. Schillinger et al. Arch Intern Med 2003;163:83 20
    18. 18. ARS: What percentage of people in the US with HTN are poorly controlled?  10%  25%  50%  75%  90%
    19. 19. Inconsistent Quality • What percent of people in the US have poorly controlled  Hypertension?  Diabetes?  Cholesterol? 25%, 50%, 75%?? 50% of people with hypertension, 80% of people with high cholesterol, 43% of people with diabetes are poorly controlled. Egan et al. JAMA 2010; 303(20):2043-2050, Ford, Internat’l J Cardiol 2010;140:226, Cheung et al. Am J Med 2009;122:443
    20. 20. The problem: panel sizes too large for primary care physicians to manage alone  A primary care physician with an panel of 2500 average patients will spend 7.4 hours per day doing recommended preventive care. Yarnall et al. Am J Public Health 2003;93:635  A primary care physician with an panel of 2500 average patients will spend 10.6 hours per day doing recommended chronic care. Ostbye et al. Annals of Fam Med 2005;3:209 Average panel size in the US is 2300 patients Alexander et al. J Gen Intern Med 2005; 20:1079-83. 23
    21. 21. Recognition That Reform and Revitalization of Primary Care is Essential for ACA and Health Care Reform to Achieve Its Goals
    22. 22. The President Wants More and Stronger Primary Care “It used to be that most of us had a family doctor; you would consult with that family doctor; they knew your history, they knew your family, they knew your children, they helped deliver babies. How do we get more primary physicians, number one; and number two, how do we give them more power so that they are the hub around which a patient-centered medical system exists, right? ” June 8, 2010, Town Hall with Seniors
    23. 23. Senator Orrin Hatch Senate Finance Committee Roundtable Reforming America’s Health Care Delivery System April 21, 2009 “The US is first in providing rescue care, but this care has little or no impact on the general population. We must put more focus on primary care and preventive medicine. How do we transform the system to do this?”
    24. 24. Randy MacDonald, Sr VP House Ways and Means Hearing April 29, 2009  “I will start with the very last question asked by the committee--what is the single most important thing to fix in healthcare? Primary care. Strengthen primary care -transform it and pay differently using a model like the Patient Centered Medical Home.”  Congressman: “And the second issue?”  “Well, if you don't fix the first issue and do not have a foundation of powerful primary care then you can do nothing else. You have to fix primary care before you can even begin to address a second issue.”
    25. 25. A 20 th Primary Care Model Will Not Meet the Demands of 21 st Century!
    26. 26. Ryan White: an Unintentional Home Builder  “An unintended consequence…. of the RW Care Act has been the establishment of the comprehensive delivery of multiple services for patients with a complex disease….medical homes for the HIV-infected person…..”  “The act created in his (Ryan White’s) memory, unintentionally created medical homes that are the best examples of how all of us should receive primary care.” Saag, M. The AIDS Reader, April 24, 2009
    27. 27. Quality:  Cervical Cancer Screening: 60%  Oral Health Exam: 36%  ARV regimens with no contraindications: 85.6%
    28. 28. Workforce The Looming Crisis in HIV Care: Who Will Provide the Care?  “In a survey conducted by HIVMA and the Forum for Collaborative HIV Research, a majority of Ryan White Part C-funded programs reported increasing caseloads and serious challenges recruiting and retaining HIV clinicians.  Reimbursement and a lack of qualified providers were the top two barriers cited.” HIV Medicine Association, 2010
    29. 29. ARS Workforce: How long have you worked in the HIV/AIDS field? 1. This is my first year 2. 1-5 years 3. 5-10 years 4. 10-15 years 5. 15-20 years 6. More than 20 years
    30. 30. Funding:
    31. 31. Engagement in HIV Care Vital Signs: HIV Prevention Through Care and Treatment -- United States. MMWR December 2, 2011/60(47);1618-1623 HIV Medical Homes Resource Center
    32. 32. Will a 20 th Century Model of HIV Care Meet the Demands of the 21 st Century Epidemic?
    33. 33. Joint Principles of the Patient Centered Medical Home February 2007 American Academy of Family Physicians American Academy of Pediatrics American College of Physicians American Osteopathic Association
    34. 34. Transforming the Delivery of Primary Care: The Patient Centered Medical Home  Ongoing Relationship with provider for first-contact, continuous, and comprehensive care;  Health Care Team that collectively cares for the patient;  Whole-person Orientation, including acute, chronic, preventive, and end-of-life care;  Coordinated Care across all elements of the health care system and the patient’s community;
    35. 35. Transforming the Delivery of Primary Care: The Patient Centered Medical Home  Quality and Safety through evidence-based medicine and clinical decision-support tools, information technology, registries, and continuous quality improvement;  Enhanced Access, achieved through such systems as open scheduling, expanded hours, and new options for communication between patients, their physician, and practice staff; and  Payment Reform to reflect the added value that a PCMH provides to patients.
    36. 36. Patient Centered Medical Home Continuous First Contact Comprehensive Coordinated HIV Medical Homes Resource Center
    37. 37. Evidence on Value of New Primary Care Models: Case Study of Group Health Cooperative of Puget Sound  Patient Centered Medical Home model piloted at one site in 2007  Avg PCP panel size reduced from 2327 to 1800  Longer face-to-face visits and scheduled time for phone and email encounters  Increased team staffing and teamwork  HIT  Panel management
    38. 38. Group Health PCMH Pilot: Controlled Evaluation 12 Month Outcomes     Improved continuity of care Better patient experiences (6 of 7 measures) Better composite quality of care score Reductions in ED visits and Ambulatory Care Sensitive Hospitalizations  No difference in total costs at year 1 (lower total costs by year 2) Source: R Reid et al. Am J Managed Care 2009;15:e71
    39. 39. Group Health PCMH Pilot: Effect on Clinic Staff 40% 34.5% 35% Percent with High Level Emotional Exhaustion 33.3% p=.02 30.0% 30% 25% Baseline 20% 12 Months 15% 9.7% 10% 5% 0% Control Sites PCMH Site
    40. 40. Change Concepts for the PCMH  Engaged Leadership  Quality Improvement Strategy  Empanelment  Continuous and Team-based Healing Relationship  Organized, Evidence-Based Care  Patient-Centered Interactions  Enhanced Access  Care Coordination Wagner, EH et al, Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes; February, 2012
    41. 41. The Building Blocks of High-Performing Primary Care: lessons from the field  23 high-performing practices  Intensive visits to 7 West Coast practices  Discussions with and observations of clinicians, RNs, MAs, front desk, leaders  High-performing practices look about the same, with variation in the details  10 building blocks -- the foundation of these practices Willard R, Bodenheimer T: CHCF April 2012
    42. 42. Building Blocks of High-Performing Primary Care: Share-the-CareTM Model
    43. 43. Change Concepts Building Blocks NCQA Recognition Engaged Leadership Data for Improvement Enhance Access/Continuity Quality Improvement Strategy Empanelment, Panel size management Identify/Manage Patient Populations Empanelment Team-based Care Plan/Manage Care Continuous and Team-based Healing Relationships Population Management Provide Self-Care Support/Community Resources Organized Evidence-based Care Continuity of Care Track/Coordinate Care Patient-Centered Interaction Prompt Access to Care Measure/Improve Performance Enhanced Access Expanded Access Template Care Coordination Mission with objectives and goals Care coordination with Medical Neighborhood Trained Leaders
    44. 44. DATA/Quality Improvement Strategy Formal QI process Defined metrics Optimized HIT Robust data collection Reporting systems to share data Strategic decisions about metrics HIV Medical Homes Resource Center Are we Data Driven organizations? Do we use real-time data on important clinical/operational data to guide day-today actions? Grant requirement to have CQI, robust metrics, early adopter of registry, variable HIT capacity
    45. 45. Empanelment Assign all patients to provider panel Balance supply and demand Use panel data to manage population Prioritizes patients seeing own PCP Clear denominator at panel level HIV Medical Homes Resource Center Is empanelment a deliberate process where we can use provider panels for quality data , proactive care and to actively manage supply and demand? Empanelment not specific grant requirement, often happens because of structure of practice
    46. 46. Team-Based Care Are our teams organized around getting the work done with an explicit vision and clear principles? With defined workflows, skills training and ground rules? Patients are connected to a Care Team Roles/tasks defined Culture shift to share-the-care. Flexible, functional teams, with clearly defined roles HIV Medical Homes Resource Center Multi-disciplinary Teams are central to RWCA
    47. 47. Team-based Care
    48. 48. 4. Team-based Care Why does teambased care matter?  Align roles to meet population needs  Non-clinician teammembers contribute to continuous healing relationship  Build capacity to make timely access possible  Foundation for the Template of the future
    49. 49. Traditional Methods of Managing Work Flow Preventive Med Intervention Chronic Disease Monitoring Medication Refill New Acute Complaint Test Results Provider Healthcare Support Team Case Manager Mental Health Provider Referral to Specialist after Assessment Certified Medical Assistant
    50. 50. Team-based care • Culture shift: share the care  Stable teamlets • Co-location  Staffing ratios  Standing orders/protocols • Defined workflows and roles – workflow mapping • Training, skills checks, and cross training • Ground rules • Communication – healthy huddles, terrific team meetings and constant conversation
    51. 51. Team-based care: stable teamlets Patient panel Clinician/MA teamlet Patient panel Clinician/MA teamlet Patient panel Clinician/MA teamlet Health coach, behavioral health professional, social worker, RN, pharmacist, panel manager, complex care manager 1 team, 3 teamlets
    52. 52. Prompt Access to Care 24/7 access to care team, patient-centered scheduling options, address barriers to access Balance supply and demand, open access, multiple channels of access HIV Medical Homes Resource Center Do we have a patientcentered approach to access? After hours coverage, +/- use of advanced access tools
    53. 53.
    54. 54. Population Management/Panel Management Plan care according to need, manage high-risk patients, point-of-care reminders Robust population management, Selfmanagement, Complex Case management, planned visits HIV Medical Homes Resource Center Are we able to focus at the population level and proactively assign resources where needed? Is data used in day-to-day care? Case Management key feature of RWCA, client level data, selfmanagement support
    55. 55. Care Coordination Link patient with community resources, referral tracking, coordination of specialty care Management of care transitions, behavioral health services, communication of results HIV Medical Homes Resource Center How good are we at managing the care that happens outside of our four walls? Comprehensive model of care, often under one-roof, expectation that transitions are tracked
    56. 56. Conscious Trained Leadership/Values and Mission Statement HIV Medical Homes Resource Center
    57. 57. 100 90 80 70 60 50 40 30 20 10 0 P C P P C P C C Series 3 Series 2 Series 1 Engagement in HIV Care Vital Signs: HIV Prevention Through Care and Treatment -- United States. MMWR December 2, 2011/60(47);1618-1623 =Access =Care Co-ordination =Population Management
    58. 58. Summary  Both Primary Care and the RWCA are at a crossroad  PCMH is one model of transformation  RWCA clinics have many components of PCMH  There is much to learn from PCMH model and high performing primary care  Our health care system will have to change to meet our goal of an AIDS Free Generation HIV Medical Homes Resource Center
    59. 59. Roadmap for Medical Home Resource Center PCMH concepts in RWCA Clinics– Action Planning Change Management of Improvement Opportunities PCMH Certification Strategic Planning Workshops TA and Virtual Learning Community for practice change TA to support certification Year 1 Year 2 Year 3