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Ndu april 2014
The document discusses the patient centered medical home (PCMH) model for improving healthcare quality and reducing costs. It provides examples of PCMH programs that have led to reductions in hospital and ER use, increased medication adherence, and lower overall healthcare costs. The PCMH model emphasizes coordinated, team-based care centered around the patient.
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Ndu april 2014
- 1. © 2014 IBMCorporation Smarter Care Paul Grundy MD, MPH - IBM Director, Healthcare Transformation March, 2014 Quality Primary Care. Reducing Costs, Improving Care Patient Centered Medical Home
- 2. © 2014 IBMCorporation 2 Smarter Care Population Health System Integrator Patient Experience The System Integrator Creates a partnership across the medical neighborhood Drives PCMH primary care redesign Offers a utility for population health and financial management Per Capita Cost Public Health Away from Episode of Care to Management of Population Hospital Community Health
- 3. © 2014 IBMCorporation 3 Smarter Care 36.3% Drop in hospital days 32.2% Drop in ER use 12.8% Increase Chronic Medication use -15.6% Total cost 10.5% Drop Inpatient specialty care costs 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 Smarter Healthcare
- 4. © 2014 IBMCorporation 4 Smarter Care • 19.1% lower rate of adult hospitalization • 8.8% lower rate of adult ER visits. • 17.7% lower rate of child ER visits (under age 17) • 7.3% lower rate of adult high-tech radiology usage http://www.crainsdetroit.com/article/20130811/NEWS/308119989/blue- cross-touts-155-million-in-savings-with-medical-home-project http://www.crainsdetroit.com/article/20130811/NEWS/308119989/blue- cross-touts-155-million-in-savings-with-medical-home-project PCMH Michigan: August 11, 2013 Medical home physicians help patients avoid ERs and admissions by evening hour appointments, weekend and same-day appointments Versus other non-PCMH designated primary care physicians. 3,017 Physicians
- 5. © 2014 IBMCorporation 5 Smarter Care Rural New York Costs for Medicaid patients dropped from $334 to $266, according to a recent “risk adjusted” analysis. http://poststar.com/news/local/medical-home-program-gains- traction/article_5811380c-2ee9-11e3-8548-001a4bcf887a.html
- 6. © 2014 IBMCorporation 6 Smarter Care Ogden UT , USA 2012
- 7. © 2014 IBMCorporation 7 Smarter Care
- 8. © 2014 IBMCorporation 8 Smarter Care MobileFirst Patient Consumer
- 9. © 2014 IBMCorporation 9 Smarter Care Today’s Care PCMH Care My patients are those who make appointments to see me My patients are those who make appointments to see me Our patients are the population community Our patients are the population community Care is determined by today’s problem and time available today Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet patient needs with or without visits Care is determined by a proactive plan to meet patient needs with or without visits Care varies by scheduled time and memory or skill of the doctor Care varies by scheduled time and memory or skill of the doctor Care is standardized according to evidence-based guidelines Care is standardized according to evidence-based guidelines Patients are responsible for coordinating their own care Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care A prepared team of professionals coordinates all patients’ care I know I deliver high quality care because I’m well trained I know I deliver high quality care because I’m well trained We measure our quality and make rapid changes to improve it We measure our quality and make rapid changes to improve it It’s up to the patient to tell us what happened to them It’s up to the patient to tell us what happened to them We track tests & consultations, and follow-up after ED & hospital We track tests & consultations, and follow-up after ED & hospital Clinic operations center on meeting the doctor’s needs Clinic operations center on meeting the doctor’s needs A multidisciplinary team works at the top of our licenses to serve patients A multidisciplinary team works at the top of our licenses to serve patients Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
- 10. © 2014 IBMCorporation 10 Smarter Care 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”
- 11. © 2014 IBMCorporation 11 Smarter Care Give me enough medals and I'll win you any war' Napoleon Bonaparte – not just the $Green$ that brings JOY The Science of Rewards, incentives
- 12. © 2014 IBMCorporation 12 Smarter Care % Total Healthcare Spend % of Members Those who are well or think they are well Those with chronic illness Those with severe, acute illness or injuries Benefit Redesign - Patient Engagement Different Strategies for Different Healthcare Spend Segments
- 13. © 2014 IBMCorporation 13 Smarter Care Preventive Medicine Medication Refills Acute Care Nursing Test Results Master Builder DOCTOR Source: Southcentral Foundation, Anchorage AK Behavioral Health Case Manager Medical Assistants Chronic Disease Monitoring Practice transformation away from episode of care
- 14. © 2014 IBMCorporation 14 Smarter Care Medication Refills Chronic Disease Monitoring Test Results Acute Care Preventive Medicine Point of Care Testing Acute Mental Health Complaint Chronic Disease Compliance Barriers Healthcare Support Team Behavioral Health Medical Assistants Case Manager Provider Source: Southcentral Foundation, Anchorage AK PCMH Parallel Team Flow Design: the glue is real data, not a doctor’s brain
- 15. © 2014 IBMCorporation 15 Smarter Care Healthcare Will Transform Data Driven Every person has a plan Team based Managing a population down to the person .
- 16. © 2014 IBMCorporation 16 Smarter Care Public Health Prevention Specialists PCMH 2.0 in Action Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers Care Coordinators Public Health Prevention HEALTH WELLNESS Hospitals PCMH PCMH Health IT Framework Global Information Framework Evaluation Framework Operations A Coordinated Health System 35
- 17. © 2014 IBMCorporation 17 Smarter Care Superb Access to Care Patient Engagement in Care Clinical Information Systems, Registry Care Coordination Team Care Communication Patient Feedback Mobile easy to use and Available Information Defining the Care Centered on Patient
- 18. © 2014 IBMCorporation 18 Smarter Care Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement Source: Hudson Valley Initiative
- 19. © 2014 IBMCorporation 19 Smarter Care 1. Pursue Electronic Patient Management and engagement rather than Electronic Patient Records 2. Bring to bear upon every patient encounter what is known rather than what a particular provider knows. 3. Make it easier to do it right than not to do it at all. 4. Continuous performance improvement. 5. Infuse new knowledge and decision- making tools throughout an organization instantly.
- 20. © 2014 IBMCorporation 20 Smarter Care 6. Establish and promote continuity of care with patient education, information and plans of care. 7. Enlist patients as partners and collaborators in their own health improvement. 8. Evaluate the care of patients and populations of patients longitudinally. 9. Audit provider performance based on the Consortium for Physician Performance Improvement Data Sets. 10. Create multiple case-management tools which are integrated in an intuitive and interchangeable fashion giving patients the benefit of expert knowledge about specific conditions while they get the benefit of a global approach to their total health
- 21. © 2014 IBMCorporation 21 Smarter Care Practices Features -- - Emphasis on care coordination and system navigation, System Integrator, PCMH role for family physician in integrated system - Big push on population health management - Care teams with PCP + a variety of other professions, e.g., nursing, pharmacy, public health and mental health. Technology Use - Better population health data stemming from centralized data based EHR through integrated system. - Adoption of telemedicine, Establish Primary Care Technology Center (PCTC), a research and training entity, to fuel adoption of efficacious technology in practice, patient engagement tools. Modern, flexible, sophisticated system, developed in partnership with technology providers. -Multi-modal communication w/ patients .
- 22. © 2014 IBMCorporation 22 Smarter Care Building a Workforce -- Training in the use of population health management, data management and public health tools - Dual degrees – MD + MBAs, MPHs - .Add’l training in interprofessional collaboration, EHR data usage, and integrated practice management. Research Focus -- Conclusive evidence about system wide quality improvement and cost savings of robust primary care.- Rise of Continuum-Based Research Networks, applied research efforts to improve clinical pathways. - Research builds case for reductions in Total Cost of Care (at system level), research into technologies most inpactful on Triple Aim. - FM becomes trusted source of best practices to meet Triple Aim, .Focus on issues that relate to patients owning their own health through patient experience and engagement research
- 23. © 2014 IBMCorporation 23 Smarter Care Collaboration -- - Family medicine’s partnership with payers and the integrated systems, to exchange ideas about how to best deploy family physicians and represent their colleagues’ interests to these systems - Subspecialists – to ensure great working relationships within systems. - Primary care professionals – to achieve the best possible outcomes in service of Triple Aim. Payers, particularly CMS – to ensure success of alternative payment pilots.- Primary Care Nurse Practitioners (to work together in pursuit of expanded role of Primary Care, Technology manufacturers) to provide advice on how to improve technology in use by FPs, Key Investments -- Curricular overhaul and research effort to prepare residents for work in integrated systems, tools for data being made into actionable information in population management, advance clinical decision support
- 24. © 2014 IBMCorporation 24 Smarter Care Three key aspects of PCMH Smarter Care coordination Provide holistic, individualized care Collaborate for better outcomes Orchestrate and integrate across the enterprise and community
- 25. © 2014 IBMCorporation 25 Smarter Care A comprehensive approach helps reduce costs while improving care Apply new insights from interactions and outcomes to enable continuous transformation LEARNING Identify and influence individuals and populations, and recognize intervention opportunities INTERVENTION COORDINATION Deliver care and monitor progress across clinical and social requirements COLLABORATION Assess and engage individuals and stakeholders to drive individualized care plans Drive evidence-based and standardized care planning KNOWLEDGE WELLNESS 25
- 26. © 2014 IBMCorporation 26 Smarter Care Thank you
- 27. © 2014 IBMCorporation 27 Smarter Care
- 28. © 2014 IBMCorporation 28 Smarter Care 28
- 29. © 2014 IBMCorporation 29 Smarter Care Trademarks and notes © IBM Corporation 2014 • IBM, the IBM logo, ibm.com, and Cúram are trademarks or registered trademarks of International Business Machines Corporation in the United States, other countries, or both. If these and other IBM trademarked terms are marked on their first occurrence in this information with the appropriate symbol (® or ™ ), these symbols indicate U.S. registered or common law trademarks owned by IBM at the time this information was published. Such trademarks may also be registered or common law trademarks in other countries. A current list of IBM trademarks is available on the Web at “Copyright and trademark information” at ibm.com/legal/copytrade.shtml. • Other company, product, and service names may be trademarks or service marks of others. • References in this publication to IBM products or services do not imply that IBM intends to make them available in all countries in which IBM operates.
Editor's Notes
- #26 Key message: We are observing leaders across communities of care coming together to support common strategies and activities, focused on improved outcomes. We’re already seeing this happen, centered on a focus on the individual. And a focus on health and wellness -- rather than just acute care, where we know much of the cost is in the system today. Why are leaders / stakeholders coming together? They have common business interests, which can sometimes even result in acquisitions and consolidations. You can engage with that individual in a number of ways: Intervention -- where we can identify populations that have common characteristics, where an early intervention can actually improve outcomes, lower costs, prevent larger issues, and minimize future costs. Knowledge -- where we can do an assessment of what really works best based on evidence and standardized care planning; all of the external information that yields insight to patients/individuals and populations Collaboration -- where we really want to drive positive health choices, to bring together stakeholders – engaging with the individual, and family members -- to drive and monitor multifaceted care plans. Provide the individual with information and support to make healthy choices; collaborate across care providers and with the individual to ensure individualized care and informed choices. Coordination – where we are sharing information among and across stakeholders. Coordinating to share knowledge and expertise, sharing a common view of the progress from care plans. Coordinating to adapt or reassess plans and results. (think of meals on wheels, employers sponsored programs, social programs, care providers, home health, etc) Learning – Really important, because as we learn about how individuals and populations respond, we must continue to evolve. Through constant learning we are analyzing information, interactions, outcomes to guide more informed decisions -- to adapt and evolve best practices. Learning is a result of engaging with multiple individuals in a population and applying the new learning into future interactions and engagements. Ensuring the community of care keeps improving, continually making progress and refining approaches that drive optimal outcomes. Constant improvement and change, to deliver improved outcomes!