This document discusses the patient centered medical home (PCMH) model and its benefits. It notes that PCMHs aim to achieve the triple aim of improved patient care, improved population health, and reduced healthcare costs. Studies show that PCMHs have led to reductions in hospital days, ER visits, and total healthcare costs, while also increasing medication adherence. The document advocates for expanding PCMHs and reforming payment systems to incentivize their growth and success.
The three pillars of healthcare reform are to increase patient safety, improve healthcare quality,
and bend the cost curve. Integration of behavioral health services in the primary care setting can
substantially contribute to all three objectives. Yet despite efforts to recruit behavioral health specialists to rural America the number of mental health profession shortage areas in the U.S. has increased 97% during the past decade. This webinar will provide actionable information that practitioners and Health Center executives can rely on to evaluate and implement telebehavioral health services successfully and thereby realize their substantial value.
The three pillars of healthcare reform are to increase patient safety, improve healthcare quality,
and bend the cost curve. Integration of behavioral health services in the primary care setting can
substantially contribute to all three objectives. Yet despite efforts to recruit behavioral health specialists to rural America the number of mental health profession shortage areas in the U.S. has increased 97% during the past decade. This webinar will provide actionable information that practitioners and Health Center executives can rely on to evaluate and implement telebehavioral health services successfully and thereby realize their substantial value.
Community-based Chronic Care ManagementBrent Feorene
A PowerPoint used in a webinar that (1) describes the importance of community-based chronic care management today and in the future; and (2) details programs that have worked. A video of the webinar is available at our web site www.housecallsolutions.com.
Presentation by Bonnie Britton, MSN, RN, ATAF Telehealth Program Administrator, Vidant Health and Seth VanEssendelft, Vice-President for Financial Services, Vidant Medical Center
Presentation by Kirby Farrell, President and CEO, Broad Axe Technology Partners and Andy Archer, MSc, MBA, Vice President, Broad Axe Technology Partners
Automated Post-Discharge Care: An Essential Tool to Reduce ReadmissionsPhytel
Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients that are discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.
Risk Stratification in Mental Health using Big Datasambiswal
Learn how risk stratification tools can help determine the likelihood of future healthcare events and increase early intervention and treatment of at-risk patients.
Personalized Health and Care: IT-enabled Personalized HealthcareIBM HealthCare
Healthcare reform currently focuses on changing the structure and incentives of the U.S. healthcare system. Healthcare transformation requires a more open, robust health information technology (HIT) environment to go beyond removing waste and inefficiencies to discover the science of health and care. Learn how IBM can make this possible.
Community-based Chronic Care ManagementBrent Feorene
A PowerPoint used in a webinar that (1) describes the importance of community-based chronic care management today and in the future; and (2) details programs that have worked. A video of the webinar is available at our web site www.housecallsolutions.com.
Presentation by Bonnie Britton, MSN, RN, ATAF Telehealth Program Administrator, Vidant Health and Seth VanEssendelft, Vice-President for Financial Services, Vidant Medical Center
Presentation by Kirby Farrell, President and CEO, Broad Axe Technology Partners and Andy Archer, MSc, MBA, Vice President, Broad Axe Technology Partners
Automated Post-Discharge Care: An Essential Tool to Reduce ReadmissionsPhytel
Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients that are discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.
Risk Stratification in Mental Health using Big Datasambiswal
Learn how risk stratification tools can help determine the likelihood of future healthcare events and increase early intervention and treatment of at-risk patients.
Personalized Health and Care: IT-enabled Personalized HealthcareIBM HealthCare
Healthcare reform currently focuses on changing the structure and incentives of the U.S. healthcare system. Healthcare transformation requires a more open, robust health information technology (HIT) environment to go beyond removing waste and inefficiencies to discover the science of health and care. Learn how IBM can make this possible.
Great Basin Primary Care Association: Overview of Patient Centered Medical Home - Standards and Preparation to obtain recognition. This presentation is targeted toward federally qualified health centers and safety net providers (primary care practices) in Nevada. Information current as of 02.25.13.
This presentation explains the concept of the patient-centered medical home (PCMH), its function and its intended effects. A brief overview of the history of PCMH is also provided, as well as a discussion of its operational characteristics, its principles and outcomes, and what is expected in the future for the PCMH model.
The highlights of this presentation covers importance of drug labeling, general labeling provisions, labeling requirements for prescription drugs and/or insulin, labeling requirements for over-the-counter (OTC) drugs, exemptions from adequate directions for use, and labeling claims for drugs in drug efficacy study.
Measuring Organizational Culture and Leadership: Evaluation of the Organizati...Marwah Zagzoug, PhD
A presentation that describes and evaluates the instrument measurement tool known as the Organizational Description Questionnaire (ODQ) to assess its reliability, validity, and usefulness in measuring organizational culture and leadership.
Patient Centered Medical home talk at WVUPaul Grundy
To employers the cost of healthcare is now a business issue and this talk is about what one large buyer IBM did to drive transformation via broad coalition with other large employers to form the Patient Centered Medical Home movement and the covenant between buyer and provider away from the garbage we now buy episodic uncoordinated disintegrated care. In the change of convenient conversation we have worked with the Primary care providers to give us coordinated, integrated, accessible and compressive care with a set of principles know as the Patient centered medical home.
A Patient Centered Medical Home (PCMH) happens when primary care healers keeping that core healing relationship with their patients step up to become specialists in Family and Community Medicine. The move is to 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. PCMH happens when the specialists in Family and Community Medicine wake up every morning and ask the question how will my team improve the health of my community today?
All over the world three huge factors are in play that is driving the concept of Patient Centered Medical Home. They are:
1) Cost and demography
2) Information technology and data (information that is actionable will equal a demand for accountability by the payer or buyer of the care)
3) Consumer demand to engage healthcare differently (at least as well as they can their bank- on line) have a question about lab results why not e-mail?
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.
Will the Revenue Ever Return? COVID-19 and the Rise of the Insurers; the Case...Health Catalyst
As healthcare providers face the long-term revenue compression of COVID-19, they’re also navigating significant industry changes. Current challenges include horizontal competition from large insurers and digital disrupters, growing telehealth volumes, headwinds from price transparency, and growth in managed care programs, like Medicare Advantage. Without restored or growing volumes, how do health systems return to profitability?
Health systems will need accurate financial data around service line and procedural profitability, which very few have. Allocations, estimates and averages of cost, and large pools of clinical “overhead” are inaccurate, and these methods have no credibility with physicians and administrators.
Join Rob DeMichiei, Strategic Advisor for Health Catalyst and former Executive Vice President and Chief Financial Officer for UPMC, to learn more.
What You’ll Learn:
- How insurers look at their medical expenses, and their plans to reduce utilization and steer volumes away from traditional providers.
- The implications of price transparency; why a rational pricing strategy is critical to success.
- Using existing EHR data to measure and assess 100 percent of your clinical costs.
- How improved costing enables service-line management and allows for improved clinical care delivery and insight into profitability.
- How activity-based costing can help identify physician and clinical variation.
- Implications of inaccurate RVU/RCC costing on contract negotiations, resource management, and productivity reporting.
- Benefits and simplicity of activity-based (consumption) costing.
What eHealth strategies work and do not work, and what should be implemented to effectively meet these healthcare “transformational” imperatives?. Crawford J. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)
Aligning Incentives for Patient Engagement: Enabling Widespread Implementation of Shared Decision Making
May 24, 2013
Jeff Thompson, Washington State Health Care Authority
David Downs, Engaged Public
David Swieskowski, Mercy ACO Mercy Clinics, Inc.
Lisa Weiss, High Value Healthcare Collaborative
Kate Chenok, Pacific Business Group on Health
The Patient-Centered Medical Home in the Transformation From Healthcare to He...Paul Grundy
Surgeon General of the Navy VADM Matthew L. Nathan, MC USN
Fortunately, we have a way to address this crisis—the
Patient-Centered Medical Home (PCMH) model launched at Naval Hospital Pensacola and Walter Reed National Military Medical Center, Bethesda, Maryland (formerly the National Naval Medical Center) in 2008. It is now being implemented throughout the Military Health System (MHS) and carries great promise. It provides the clinical framework we need to meet our strategic objectives in terms of quality of care, impact on costs, population health, and readiness. One of the most significant benefits of the team-based, collaborative approach is that it allows us to embed within a primary care environment the psychologists, nutritionists, tobacco cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the “mental armor,” our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations. As we move ahead with this more comprehensive approach to health, we can begin to better address so many of our patients for whom we can find no specific reason for pain and discomfort. The PCMH model also provides a positive impact on our costs. Early data reporting from the PCMH clinics at Bethesda show reduced visits to the emergency room, lowered pharmacy costs, and significant per beneficiary per year savings and improved Healthcare Effectiveness Data and Information Set metrics, access, and patient satisfaction and trust. These positive impacts on the bottom line can be applied directly to improved costs or toward the reallocation of resources from reimbursing those who are sick to the population health-based programs that can make and keep our patients healthy.More significant, however, the PCMH environment allows us to go beyond mere collaboration and to a much more proactive approach to managing our patient populations. It is within the context of the medical home that we can begin to surround our patients with the tools and resources they need to move them from health care to health.
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
National Conference on Health and Domestic Violence. Plenary talk Paul Grundy
explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967.
This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home.
The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.
PCMH implementation, highly associated with important outcomes for both patients and providers. The rate of emergency department visits was significantly
lower in sites with more PCMH effective implementation. Efficient PCMH implementation favorably associated with patient satisfaction, staff burnout, quality of care, and use of health care services.
A systematic review of the challenges to implementation of the patient-centre...Paul Grundy
review the available literature to identify the major challenges and barriers to implementation and adoption of the patient-centred medical home (PCMH) model, topical in current Australian primary care reforms. documents the key challenges and barriers to implementing the PCMH model in United States family practice. It provides valuable
evidence for Australian clinicians, policymakers, and
organisations approaching adoption of PCMH elements
within reform initiatives in Australia.
"'I am proud that MaineCare has been working in partnership with other payers to advance payment reform through greater investment in primary care to both improve outcomes for patients and reduce preventable high cost spending in emergency departments and avoidable inpatient admissions.
– Mary C. Mayhew, Commissioner, Maine Department of Health & Human Services
Effective integration of specialty practices into medical neighborhoods is likely to require several important environmental precursors. First, a sound infrastructure
design can connect PCMHs to the spectrum of surrounding
specialty practices. An aligned information architecture
will be vital to adequate patient access, care coordination, and communication. Second, a patient centered
neighborhood will rely on an organizational culture that
supports shared learning and transparency of performance and cost data among participating practices. Third, payment incentives will have to be aligned around shared accountability for outcome and cost. Responsibility
for outcomes and total cost of care will have to rest not only with primary care clinicians, but also with specialists who perform(often expensive) procedures and specialty services.The launch of the NCQA’s PCSP recognition program is a sign of a new phase of delivery system reform
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.
OVERVIEW -- Care by Design - Putting Care back into healthcare the University of Utah experience in building PCMH level care over the decade of 2001 to . 2011
Care by design magill lloyd successful turnaroundPaul Grundy
The University of Utah purchased a 100-clinician, 9-practice multispecialty primary care network in 1998. The university projected the network to earn a profit the first year of its ownership in a market with growing capitation; however, capitation declined and the network incurred up to a $21 million operating loss per year. This case study describes the financial turnaround of the network.
Care by design 2 bodenheimer teams 2 utah chapterPaul Grundy
Putting Care back into healthcare the University of Utah experience in building PCMH level care. this talks about the team base experice as written up in 2007 by Tom Bodenheimer.
New zealand cantabury timmins-ham-sept13Paul Grundy
This is a great example of a community in New Zealand of the interrogation of social services and healthcare. They are changing the demand curve and getting away from “we need more and more resources to see more patients”. The language we use, very deliberately, is “right care, right place, right time”. Once you start getting the whole
system to work as one system, it starts flushing out unnecessary expenditure. So you can do more and/or do it better.’ worth a read.
I did a visit to new zealand in 2003 and did a number of talks from 2003 to 2005 on the transformation taking place in new zealand. back in NZ in 2014 so looked at those early slide so impressed with the leadership and the robust primary care
, patients reported higher overall satisfaction at a primary care practice that adopted the patient-centered medical home model along with lean process changes and physician payment reform.
.......................................................................................................
South central foundation Alaska
If you are in a mechanical manufacturing environment then hitting a target is a matter much like the throwing of a rock – figuring out speed trajectory
If you are in a messy, human, complex, adaptive environment it is like throwing a
bird at a target – it is all about the ‘attractor’
Healthcare mostly throws birds at targets and only thinks about the throwing part than wonders why the Human fails to hit the target
2. Paul Grundy, MD, MPH, FACOEM, FACPM
IBM Director Healthcare Transformation
President Patient Centered Primary Care Collaborative
3.
4. “We'll bring down costs by changing the way our
government pays, because our medical bills
shouldn't be based on the number of tests
ordered or days spent in the hospital.
They should be based on the quality of care”
5. OPM Carrier Letter Feb 5th 2013
Patient Centered Medical Homes (PCMH) within the Federal
Employees Health Benefits (FEHB) Program
• Triple Aim of improved patient care, improved population
health, and reduced health care costs
• A growing body of evidence supports investment in
PCMH
• there must be a plan for all FEHB lives
enrolled in the practice to be included in a reasonable
timeframe.
6. Triple Aim - A move Away from Episode of Care to
Management of Population – What we are good at
Population Per
Health Capita
Cost
System Integrator
Patient Productivity The System Integrator
Experience Creates a partnership across the
medical neighborhood
Drives PCMH primary care redesign
Offers a utility for population health
and financial management
7. Smarter Healthcare
36.3% Drop in hospital days
32.2% Drop in ER use
12.8% Increase Chronic Medication use
-15.6% Total cost
10.5% Inpatient specialty care costs down
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
8. WellPoint PCMH Preliminary Year 2 Highlights In Sept Issue
Health affairs 2012
• 18% decrease in acute IP admissions/1000,
compared to 18% increase in control group
Colarado • 15% decrease in total ER visits/1000, compared to
4% increase in control group
• Specialty visits/1000 remained around flat
NEW HAMPSHIRE
compared to 10% increase in control group
• Overall Return on Investment estimates ranged
between 2.5:1 and 4.5:1
New York
9. Blue Plan Care Delivery Innovations
PCMHs/ACOs are in market or in development in 49 states, District of Columbia and Puerto Rico,
bringing the total number of patient centered organizations to 204
10. United PCMH
• internal assessment of the first four pilots that were
launched in Arizona, Colorado, Ohio, and Rhode Island
starting in 2009 . Compared to a control group of similar
patients, and averaged across the four pilots over two
years
• gross savings on medical -costs were in the range of 4 .
0 percent to 4 .5 percent lower per year
• thus generating a 2:1 return on investment — at the
same time that notable improvements in care quality
measures were observed
11.
12. “We do the best
heart surgeries.”
“How to Stop Hospitals From Killing Us”
WSJ Friday 21 Sept 2012
17. Least Expensive Most Expensive
Ogden, UT $2,623 Anderson, IN $7,231
Dubuque, IA $2,719 Punta Gorda, FL $7,168
Fargo, ND $2,996 Racine, WI $6,528
Boston, Ma $6,432
20. Hospital as Employer Build PCMH own Employees
$804 Per Employee Per Month
$805
$765 Health Costs
Post Implementation
Actual client data: Midwest
Hospital with 12,135
employees 1 year self-funded
$569
for group health
http://www.nytimes.com/2012/09/03/opinion/health-care-where-you-work.html
21. Montana Governor “sees big savings
with new state PCMH health clinic
• PCMH for every beneficiary
• Better coordination of care
• Prevent ER, Hospital
• Unneeded Expensive test
• Saving $100 million 5 years
• Employee health clinics up 36%
22.
23.
24. What needs to change?
1. Delivery
2. Payment
3. Health care benefits
25. Practice transformation away from episode of care
Preventive Chronic Disease Medication
Medicine Monitoring Refills Acute Care Test Results
DOCTOR
Case Behavioral Medical
Master Builder
Manager Health Assistants Nursing
Source: Southcentral Foundation, Anchorage AK
26. Healthcare will transform
• Data Driven
• Every patient has a plan
• Team based
BCBS as the largest will drive it
Or be consumed by it
27. Defining the Care Centered on Patient
Superb Access
to Care Team Care
Patient Engagement
in Care Patient Feedback
Clinical Information
Systems, Registry
Publicly Available
Information
Care Coordination
28. 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”
29. Benefit Redesign - Patient Engagement Different Strategies for
Different Healthcare Spend Segments
Those with
severe, acute
illness or injuries
Those with
% Total chronic illness
Healthcare Those who are well or
think they are well
Spend
30. PCMH in Action
A Coordinated
Health System
Hospitals Community Care Team Health IT
Nurse Coordinator Framework
PCMH Social Workers
Dieticians Global Information
Community Health Workers Framework
Specialists
Care Coordinators
Evaluation
PCMH Public Health Prevention Framework
HEALTH WELLNESS
Public Health Operations
Prevention
35. The Institute of Medicine’s 2012, 385-page report,
Best Care at Lower Cost:
Primary care providers are the only healthcare
professionals who can effect transformation in
health care. The systems and structures which will
fulfill the Triple Aim (IHI) can only be designed and
implemented by primary Healthcare Healers.