The document discusses the medical home model of patient-centered primary care. It outlines the challenges currently facing primary care and describes the design principles of the medical home model, which aims to improve care coordination, access, and patient engagement. Pilot outcomes data from Group Health showed improved quality measures, patient/staff satisfaction, and reduced costs with the medical home model over 2 years.

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

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. 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)

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. 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. Challenges Overcome

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

14. Nursing Boards

17. Transition to the Future Medical Home Model

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. Transformational Thinking See what’s not there Reframe Move Think about nature Journalistic Six Word Association Change your lens

21. Care & Facility Redesign Opportunities