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© 2014 IBM Corporation
Smarter Care
Paul Grundy MD, MPH - IBM Director, Healthcare Transformation
March, 2014
Quality Primary Care. Reducing Costs, Improving Care
Patient Centered Medical Home
© 2014 IBM Corporation 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
© 2014 IBM Corporation 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
© 2014 IBM Corporation 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
© 2014 IBM Corporation 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
© 2014 IBM Corporation 6
Smarter Care
Ogden UT ,
USA 2012
© 2014 IBM Corporation 7
Smarter Care
© 2014 IBM Corporation 8
Smarter Care
MobileFirst Patient Consumer
© 2014 IBM Corporation 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
© 2014 IBM Corporation 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”
© 2014 IBM Corporation 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
© 2014 IBM Corporation 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
© 2014 IBM Corporation 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
© 2014 IBM Corporation 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
© 2014 IBM Corporation 15
Smarter Care
Healthcare Will Transform
Data Driven
Every person has a plan
Team based
Managing a population
down to the person
.
© 2014 IBM Corporation 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
© 2014 IBM Corporation 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
© 2014 IBM Corporation 18
Smarter Care
Trajectory to Value Based Purchasing:
Achieving Real Care Coordination and
Outcome Measurement
Source: Hudson Valley Initiative
© 2014 IBM Corporation 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.
© 2014 IBM Corporation 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
© 2014 IBM Corporation 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 .
© 2014 IBM Corporation 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
© 2014 IBM Corporation 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
© 2014 IBM Corporation 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
© 2014 IBM Corporation 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
© 2014 IBM Corporation 26
Smarter Care
Thank you
© 2014 IBM Corporation 27
Smarter Care
© 2014 IBM Corporation 28
Smarter Care
28
© 2014 IBM Corporation 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.

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Ndu april 2014

  • 1. © 2014 IBM Corporation 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 IBM Corporation 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 IBM Corporation 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 IBM Corporation 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 IBM Corporation 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 IBM Corporation 6 Smarter Care Ogden UT , USA 2012
  • 7. © 2014 IBM Corporation 7 Smarter Care
  • 8. © 2014 IBM Corporation 8 Smarter Care MobileFirst Patient Consumer
  • 9. © 2014 IBM Corporation 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 IBM Corporation 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 IBM Corporation 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 IBM Corporation 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 IBM Corporation 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 IBM Corporation 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 IBM Corporation 15 Smarter Care Healthcare Will Transform Data Driven Every person has a plan Team based Managing a population down to the person .
  • 16. © 2014 IBM Corporation 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 IBM Corporation 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 IBM Corporation 18 Smarter Care Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement Source: Hudson Valley Initiative
  • 19. © 2014 IBM Corporation 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 IBM Corporation 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 IBM Corporation 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 IBM Corporation 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 IBM Corporation 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 IBM Corporation 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 IBM Corporation 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 IBM Corporation 26 Smarter Care Thank you
  • 27. © 2014 IBM Corporation 27 Smarter Care
  • 28. © 2014 IBM Corporation 28 Smarter Care 28
  • 29. © 2014 IBM Corporation 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

  1. 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!