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.

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Paul Grundy MD, MPH - IBM Director, Healthcare Transformation
March, 2014
Quality Primary Care. Reducing Costs, Improving Care
Patient Centered Medical Home

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Paul Grundy MD MPH Bio
• “Godfather” of the Patient Centered Medical Home
• IBM Global Director Healthcare Transformation
• President of PCPCC
• Member Institute of Medicine
• Member Board ACGME
• Professor Univ. of Utah Department Family Medicine
• Winner NCQA national Quality Award
• A Leader of MOH level taskforce primary care transformation 8
nations: USA, Canada, New Zealand, Australia, Holland,
Denmark, UK, Belgium,
• Univ. of California MD, John Hopkins Trained

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Reengineering for Health Care
Three types of businesses undertake reengineering:
• Those at the peak of their game & ambitious executives
•those that reengineer to stay ahead, and
•those in deep trouble.
The US health care system is in trouble, and rather than
single reforms, it needs and is getting reengineered.
•7 days to 4 hours # of deals increased a 100 fold
JAMA - Feb 2013, Ari Hoffman, MD, Ezekiel J. Emanuel, MD, PhD

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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

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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

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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

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JAMA Article

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44% reduction in hospital costs
21% reduction in overall medical costs.
160 PCMH practices Pennsylvania from 2009 to 12
Number of patients with poorly controlled diabetes declined
by 45% Jeffrey Bendix modernmedicine.com
http://www.ajmc.com/publications/issue/2014/2014-vol20-
n3/Medical-Homes-and-Cost-and-Utilization-Among-High-Risk-
Patients#sthash.qR8uWb4t.dpuf
PCMH Pennsylvania March, 2013
Conclusions: PCMH practices had significantly reduced costs
and utilization for the highest risk patients, particularly with
respect to inpatient care.

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Ogden UT ,
USA 2012

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MobileFirst Patient Consumer

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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

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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

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Trajectory to Value Based Purchasing:
Achieving Real Care Coordination and
Outcome Measurement
Source: Hudson Valley Initiative

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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”

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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

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% 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

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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

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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

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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 ProviderClinician
Source: Southcentral Foundation, Anchorage
AK
PCMH Parallel Team Flow Design: the glue is real data,
not a doctor’s brain

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Healthcare Will Transform
Data Driven
Every person has a plan
Team based
Managing a population
down to the person
.

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Three key aspects of PCMH Smarter Care coordination
Provide holistic,
individualized care
Collaborate for better
outcomes
Orchestrate and integrate
across the enterprise and
community

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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.

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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

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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 .

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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

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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

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Thank you

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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
3

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3

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Trademarks and notes
© IBM Corporation 2014
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