SlideShare a Scribd company logo
Extracting Value 
Patient Centered Medical Home 
Paul Grundy MD, MPH - IBM Director, Healthcare Transformation 
@Paul_PCPCC 
https://twitter.com/Paul_PCPCC
Ancestors
Away from Episode of Care to Management of Population 
The System Integrator 
Creates a partnership across the 
medical neighborhood 
Drives PCMH primary care redesign 
Offers a utility for population health 
and financial management 
WITH DATA 
Population 
Health 
System Integrator 
Patient 
Experience 
Community Health 
Per 
Capita 
Cost 
Public 
Health @Paul_PCPCC 
https://twitter.com/Paul_PCPCC
In much of the world, no one is in charge. 
And the result is the most wasteful and Unsustainable 
– BUT -where the delivery system works 
– a Patient in a trusting relation with a 
healer who is a comprehensivist with 
data is in charge”
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% 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
24 July 2014 Michigan Blues’ patient-centered medical home program 
shows statewide transformation of care YEAR 6 
•9.9 percent lower rate of adult ER visits 
•27.5 percent lower rate of adult ambulatory care sensitive 
inpatient stays 
•11.8 percent lower rate of adult primary care sensitive ER 
visits 
•8.7 percent lower rate of adult high-tech radiology usage 
•14.9 percent lower rate of pediatric ER visits 
•21.3 percent lower rate of pediatric primary-care sensitive ER 
visits 
4,022 primary care doctors at 1,422 practices around the state 
in its sixth year of operation. These practices care for more 
than 1.2 million BCBSM members.
Beyond Flexner --- Driven by 
Actionable - Personalized Data
USA 2012 
Ogden UT
Oslo paul grundy nov 2014
MobileFirst Patient Consumer
Practice transformation away from episode of 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
PCMH Parallel Team Flow Design: the glue is real data, not a doctor’s brain 
Chronic 
Disease 
Monitoring 
Medication 
Refills 
Test 
Results 
Acute 
Care 
Source: Southcentral Foundation, Anchorage AK 
Preventive 
Medicine 
Point of 
Care Testing 
Acute 
Mental 
Health 
Complaint 
Chronic 
Disease 
Compliance 
Barriers 
Healthcare 
Support 
Team Behavioral 
Health 
Medical 
Assistants 
Case 
Manager Clinician
Healthcare Will Transform --- Family Medicine for America’s Health 
Data Driven 
Every person has a plan 
Team based 
Managing a population 
down to the person 
.
Today’s Care PCMH Care 
My patients are those who make appointments to see 
me 
Our patients are the population community 
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 varies by scheduled time and memory or skill of 
the doctor 
Care is standardized according to evidence-based 
guidelines 
Patients are responsible for coordinating their own 
care 
A prepared team of professionals coordinates all 
patients’ care 
I know I deliver high quality care because I’m well 
trained 
We measure our quality and make rapid changes to 
improve it 
It’s up to the patient to tell us what happened to them 
We track tests & consultations, and follow-up after 
ED & hospital 
Clinic operations center on meeting the doctor’s 
needs 
A multidisciplinary team works at the top of our 
licenses to serve patients 
Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
Defining the Care Centered on Patient 
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
Primary Care 
Capacity: 
Patient 
Centered 
Medical Home 
HIT 
Infrastructure: 
EHRs and 
Connectivity 
Operational 
Care 
Coordination: 
Embedded RN 
Coordinator and 
Health Plan Care 
Coordination $ 
Value/ Outcome 
Measurement: 
Reporting of Quality, 
Utilization and Patient 
Satisfaction Measures 
Value-Based 
Purchasing: 
Reimbursement 
Tied to 
Performance on 
Value (quality, 
appropriate 
utilization and 
patient satisfaction) 
Achieve Supportive 
Base for ACOs and 
Bundled Payments 
with Outcome 
Measurement and 
Health Plan 
Involvement 
Trajectory to Value Based Purchasing: 
Achieving Real Care Coordination and 
Outcome Measurement 
Source: Hudson Valley Initiative
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”
Benefit Redesign - Patient Engagement 
Different Strategies for Different Healthcare Spend Segments 
% 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
Specialists 
Public Health 
Prevention 
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 
A Coordinated 
Health System 
Health IT 
Framework 
Global Information 
Framework 
Evaluation 
Framework 
Operations
Thank you
Oslo paul grundy nov 2014
A comprehensive approach helps reduce costs while improving care 
INTERVENTION 
Identify and influence individuals 
and populations, and recognize 
intervention opportunities 
LEARNING 
Apply new insights from 
interactions and outcomes 
to enable continuous 
transformation 
COORDINATION 
KNOWLEDGE 
Drive evidence-based and 
standardized care planning 
Deliver care and monitor progress across 
clinical and social requirements 
COLLABORATION 
Assess and engage 
individuals and 
stakeholders to drive 
individualized care plans 
WELLNESS

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Oslo paul grundy nov 2014

  • 1. Extracting Value Patient Centered Medical Home Paul Grundy MD, MPH - IBM Director, Healthcare Transformation @Paul_PCPCC https://twitter.com/Paul_PCPCC
  • 3. Away from Episode of Care to Management of Population The System Integrator Creates a partnership across the medical neighborhood Drives PCMH primary care redesign Offers a utility for population health and financial management WITH DATA Population Health System Integrator Patient Experience Community Health Per Capita Cost Public Health @Paul_PCPCC https://twitter.com/Paul_PCPCC
  • 4. In much of the world, no one is in charge. And the result is the most wasteful and Unsustainable – BUT -where the delivery system works – a Patient in a trusting relation with a healer who is a comprehensivist with data is in charge”
  • 5. 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% 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
  • 6. 24 July 2014 Michigan Blues’ patient-centered medical home program shows statewide transformation of care YEAR 6 •9.9 percent lower rate of adult ER visits •27.5 percent lower rate of adult ambulatory care sensitive inpatient stays •11.8 percent lower rate of adult primary care sensitive ER visits •8.7 percent lower rate of adult high-tech radiology usage •14.9 percent lower rate of pediatric ER visits •21.3 percent lower rate of pediatric primary-care sensitive ER visits 4,022 primary care doctors at 1,422 practices around the state in its sixth year of operation. These practices care for more than 1.2 million BCBSM members.
  • 7. Beyond Flexner --- Driven by Actionable - Personalized Data
  • 11. Practice transformation away from episode of 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
  • 12. PCMH Parallel Team Flow Design: the glue is real data, not a doctor’s brain Chronic Disease Monitoring Medication Refills Test Results Acute Care Source: Southcentral Foundation, Anchorage AK Preventive Medicine Point of Care Testing Acute Mental Health Complaint Chronic Disease Compliance Barriers Healthcare Support Team Behavioral Health Medical Assistants Case Manager Clinician
  • 13. Healthcare Will Transform --- Family Medicine for America’s Health Data Driven Every person has a plan Team based Managing a population down to the person .
  • 14. Today’s Care PCMH Care My patients are those who make appointments to see me Our patients are the population community 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 varies by scheduled time and memory or skill of the doctor Care is standardized according to evidence-based guidelines Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care I know I deliver high quality care because I’m well trained We measure our quality and make rapid changes to improve it It’s up to the patient to tell us what happened to them We track tests & consultations, and follow-up after ED & hospital Clinic operations center on meeting the doctor’s needs A multidisciplinary team works at the top of our licenses to serve patients Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
  • 15. Defining the Care Centered on Patient 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
  • 16. Primary Care Capacity: Patient Centered Medical Home HIT Infrastructure: EHRs and Connectivity Operational Care Coordination: Embedded RN Coordinator and Health Plan Care Coordination $ Value/ Outcome Measurement: Reporting of Quality, Utilization and Patient Satisfaction Measures Value-Based Purchasing: Reimbursement Tied to Performance on Value (quality, appropriate utilization and patient satisfaction) Achieve Supportive Base for ACOs and Bundled Payments with Outcome Measurement and Health Plan Involvement Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement Source: Hudson Valley Initiative
  • 17. 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”
  • 18. Benefit Redesign - Patient Engagement Different Strategies for Different Healthcare Spend Segments % 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
  • 19. Specialists Public Health Prevention 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 A Coordinated Health System Health IT Framework Global Information Framework Evaluation Framework Operations
  • 22. A comprehensive approach helps reduce costs while improving care INTERVENTION Identify and influence individuals and populations, and recognize intervention opportunities LEARNING Apply new insights from interactions and outcomes to enable continuous transformation COORDINATION KNOWLEDGE Drive evidence-based and standardized care planning Deliver care and monitor progress across clinical and social requirements COLLABORATION Assess and engage individuals and stakeholders to drive individualized care plans WELLNESS