Transcript Transitions of Care - Harvard Skin Disease Research Center

Primary Care Update
Dermatology Faculty Meeting
Joe Frolkis
January 24, 2013
The Decisive Moment
Behind the Gare St
Lazare
The “Decisive Moment” in Health Care
• Unsustainable cost (18% GDP; 2x inflation)
• Poor Quality Compared to Other, Similar
Economies (Rank 37th Internationally)
• Lack of Access, Persistent Disparities
• Significant Waste (Estimates of 2030%=$700b/yr)
• Fragmented Care Leads to Patient Harm (IOM)
Fragmented Care: Nearly Half of U.S. Adults Report Failures to
Coordinate Care
Percent U.S. adults reported in past two years:
Your specialist did not receive basic
medical information from your
primary care doctor
13
Your primary care doctor did not
receive a report back from a specialist
15
Test results/medical records were not
available at the time of appointment
19
Doctors failed to provide important
medical information to other doctors
or nurses you think should have it
No one contacted you about
test results, or you had to call
repeatedly to get results
21
25
Any of the above
47
0
20
40
Source: S. K. H. How, A. Shih, J. Lau, and C. Schoen, Public Views on U.S. Health System Organization:
A Call for New Directions (New York: The Commonwealth Fund, Aug. 2008).
60
Only 65 Percent of US Adults Report Having
an Accessible Personal Clinician
Percent of adults ages 19–64 with an accessible primary care provider*
U.S. Average
66
2002
65
2005
U.S. Variation 2005
69
White
59
Black
49
Hispanic
73
400% + of poverty
200% –399% of poverty
63
53
<200% of poverty
74
Insured all year
51
Uninsured part year
37
Uninsured all year
0
20
40
60
80
100
* An accessible primary care provider is defined as a usual source of care who provides preventive care, care for new
and ongoing health problems, referrals, and who is easy to get to.
Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.
Source: The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results
from the National Scorecard on U.S. Health System Performance, 2008 (New York: The Commonwealth Fund, July 2008).
Supply Driving Demand:
Overutilization of Resources
20-30% of US Health Care Spending is
Estimated to be “Waste”
PC’s Impact on the Health of Society
(Just a Moment on the Soap Box)
• When compared with other developed countries, the United
States ranked lowest in its primary care functions and lowest in
health care outcomes, yet highest in health care spending.
• States with higher ratios of PCPs to population have better
health outcomes, including decreased mortality from cancer,
heart disease, or stroke, and lower costs and hospitalization
rates.
• An increase of 1 primary care physician per 10,000 population
in a state was associated with a rise in that state's quality rank
by more than 10 places and a reduction in overall spending by
$684 per Medicare beneficiary.
• The more that complex, chronically-ill patients are attached to
a PC practice, the lower are overall health system costs (all
medical services, hospital services, and drugs).
7
The Primary Care Crisis
• Critical current shortage of Primary Care
Physicians (Only 2% of medical students plan
PC careers)
• That will only worsen:
– Projected shortage of ~ 65,000 PCPs by 2025 when
include the 32 mm “covered lives” under PP-ACA
– Aging of population (# >65 will grow from 35 to 70
mm by 2030)
– Multiple co-morbidities normative in this group
– Medical advances mean that care moving
inexorably into the ambulatory setting
Reasons for the Shortage Not Hard to Find
• Primary Care Physicians earn 55% of the average specialist
salary (leave $3-4mm “on the table” across a career)
• For a panel of 2500 patients, PCP’s would have to work 23
hours a day to provide all recommended acute, chronic, and
preventive care (no current compensation under FFS for the
onerous burden of care coordination)
• Typical PCP works with 229 other physicians to manage his/her
panel
• Burn out a major problem:
If you (PCP’s) had to do your career over again :
– 28% would do again
– 41% would be a specialist
– 27% would not be a physician
• Physician’s Foundation 10/08
The Paradigm Shift
Current Model
• Incented by Volume
• Focus on Physician
• Focus on Acute Illness,
high margin services
• Focus on individual
patient
• Fill Beds
• Payor has more risk
•
•
•
•
•
•
Evolving Model
Incented by Value
Focus on Team
Focus on prevention,
care coordination
Focus on population
Prevent unnecessary
utilization
Provider has more risk
Navigating the Bridge from Fee-for-Service to
Accountable Care
Key Strategies for Primary Care Strategy Transformation
Assemble a High-Performance Primary Care
Transition Practice
Network
Operations
• Grow and organize the
• Transform in-practice care delivery
PCP network of the future
• Enhance patient primary care access
• Create the primary care team
• Anchor a cooperative care network
100%
Create a Sustainable
Financial Model
• Craft strategy-aligned PCP
compensation
• Leverage payment incentives to
support practice transformation
Primary Care Returns Across the Transition to Accountable Payment
Realizing Returns Today
Revenue
Generated
Total Cost
Accountability
Preparing for Tomorrow
• Improved performance on key
quality and cost initiatives
• Increased practice access, patient
visit volume
• Stabilized PCP
practice retention
• Infrastructure base for care
coordination, management, patient
engagement
• Patients treated at lowest-cost site, by
lowest-level
provider possible
• Expanded panel size
Fee for Service
0%
Time
Source: Health Care Advisory Board
interviews and analysis.
Short term implications
• Panel sizes will grow (fewer PCPs/more patients)
• Multidisciplinary PC teams will be necessary to
manage care
• The 1:1 MD-Pt encounter will no longer be the sole
clinical care experience in PC
• PCPs will be needed to both see the most complex
cases and to manage the team (skills not currently
taught)
• PCMH emerging as one model that captures these
core concepts
12
Patient-Centered Medical Home
(Great Medical Care, Delivered by a Team)
• Team-based acute, chronic, preventive and coordinated
care
• Patient-centered care (improved access, e-visits, SMAs,
extended hours, pt engagement)
• New model of care delivery (evidence-based population
management; performance measurement and
improvement; interoperable IT)
• Need for underlying payment reform (severity adjusted
reimbursement for care management, coordination,
quality, outcomes) to make model viable, sustainable
13
High-functioning Teams Require New Roles
(And is much less MD-Centric)
• Other care providers
–
–
–
–
Advanced Practice Clinicians (NPs, PAs)
Pharmacists
Social Workers
Nutritionists
• Population manager
– reviews registry, calls patients
• Care manager
– provides more intensive management/follow-up for high risk patients
• the 20% who are 80% of the cost
• Medicare patient with 4 or more chronic problems
• Self-management Coach
• The 80% who are 20% of the cost, but will be the 20% who are 80% of the
cost in 20 years
• Care Coordinator
– tracks referrals/testing, and transitions in care
14
The Implications of Being Truly Patient-Centered
“Virtually all physicians and hospitals throughout
the world say ‘Patients come first’—but relatively
few are ready to act on the implications of this
slogan, which include ‘Physicians come second.’”
Source: Lee T and Mongan J. Chaos and Organization in Health Care. Cambridge: The MIT Press, 2009; Health Care
Advisory Board interviews and analysis.
Primary Care at BWF
and
“Phase 1” Strategic Work
The “Value Proposition” for Team-Based Primary Care
Key entry point for patients into the system and trusted “home base” for their
subsequent experiences of care
Provides care that is:
- first contact
- continuous (across the life cycle)
- comprehensive (disease prevention, health promotion/education, patient and
family empowerment, acute care, care of chronic illness, palliative care)
- coordinated across spectrum of illness (subspecialty care, acute hospitalization,
rehab, home health, nursing home)
Provides a platform for:
- population management
- high risk patient management
- chronic disease management
- effective resource utilization, decreased cost
- improved access
- improved patient satisfaction
- improved quality and clinical outcomes
- building a high-functioning medical neighborhood
18
BWH Primary Care: “The Mission”
• Create a sustainable practice model (team-based care) that
recognizes the diversity of individual practices
• Reduce variability, demonstrate excellence across all practices
re: quality, access, patient satisfaction, cost
• Use these achievements to:
- Build a BWH-PC reputation that matches that of the inpatient side of the institution
- Restore professional pride and quality of life
- Increase job satisfaction, professional growth, and
retention
- Attract the “best and brightest” back to BWH-PC
• Make sure the new model readies PC and BWH for the
implications of “Accountable” care: reducing unnecessary ED
utilization, 30-day readmissions, bundled payments, etc
BWH Primary Care Multi-Year Strategy
• Expand Clinical Work Force
- MD’s: Ongoing Recruitment (31 New Hires since 10/2009)
- APC’s: Employ as direct care providers
• Invest in Creating A Team-Based Care Model (PCMH)
- Stage I (2011-12): Improve Staffing Ratios of core clinical (LPN, MA, RN) and
non-clinical (front desk, admin) support staff to improve access, productivity
- Stage II (2013-15): Add SW, Nutrition, Pharmacists, Population Mgr to create
“fully-functional” teams
• Expand Capacity
- Add new practices: SH, Norwood (6/12/12), BFP (HVMA; 1/13)
- Augment, consolidate current practices (FXB FY13, FH ?FY14)
• Enlarge Geographic Foot Print
- PHS Business Planning suggests “southern strategy”: FXB-FH
• Support use of FH for appropriate secondary, tertiary services
Current BWH Practices
(Centered in Southern Urban Core)
Practice Type
Practice Name
Hospital Licensed Practice
The Phyllis Jen Center for Primary Care
Brigham Circle Medical Associates
Brigham Physicians Group
The Fish Center for Women’s Health, Primary Care
Practice
Brigham and Women’s Advanced Primary Care
Associates, South Huntington (8/2011)
Physician Office Practice
Brigham and Women’s at Newton Corner
Brigham and Women’s at Foxborough
Brigham and Women’s at Brookline
Brigham Primary Physicians
Faulkner Community Physicians
Brigham and Women’s at Norwood (6/2012)
Community Health Centers
Brookside Community Health Center
Southern Jamaica Plain Health Center
The Spanish Clinic
21
21
BWH Primary Care Vital Statistics
2006
2009
2010
2011
2012
2006 - 2012
% Change
Number Of PCPs
121
128
135
145
157
30%
PCP FTEs
63.7
73.7
78.3
81.9
92.04
44%
APC FTEs
3.91
15.75
15.25
15.25
16.71
327%
Total Visits
181,486
204,405
210,220
216,850
226,517
25%
Total New Visits
7,561
10,341
10,642
11,926
13,652
81%
Creating Team-Based Care, Phase 1
Work to Date: FY 10 – 12
(Goals-Metrics-Skills-Implementation)
•
•
•
•
•
Strategic Planning Process
PC Dashboard
Leadership Development
Implementation (Gap to Goal work)
Grow Enterprise (Recruitment, New Practices)
23
Tenets of the BWH PC Practice of the Future
(“Goals”)
•
•
•
•
•
•
Patient-Centered Care
Team-Based Care
Value-Based Payment
Practice Standards and Expectations
HIT-Facilitated Population Care
Multi-Disciplinary Primary Care Workforce
PC Dashboard
(“Metrics”)
• Develop common set of performance goals and
metrics by which to evaluate them
• Link goals, metrics to Strategic Plan
• Share practice –level data transparently at
Leadership meetings (leverage our competitiveness)
• Work with individual practices to prioritize PI efforts
• Work with CCE toward physician-level data
25
BWH Primary Care Dashboard
Categories of Measures
Practice Snapshot
• MD FTE, Total MD’s/APC’s
• Annualized Visits/MD FTE
• Panel Size/MD FTE
• Total New Patients
Patient Experience
• Press Ganey: Survey Mean
• Press Ganey: Overall
Assessment
Billing Performance
• Charge Lag
• Co-Pay Collection Rate
• Days in Accounts Receivable
Quality Metrics
BWPO P4P
• Diabetes (A1c, LDL, BP)
• Cardiovascular Disease (LDL,
BP)
• Hypertension (BP)
Access
• Press Ganey: Access to Care
• New Visit Appointment Lag
• Patient Gateway Utilization
Transitions of Care
(“ACO Metrics”)
• 30-day Readmission Rate
• ED Utilization
• F/U Appointment Post
Hospital D/C
26
Patient Satisfaction: Overall Assessment (through Jan fy11)
Category: Patient Experience of Care
100
92.6 = BWH Goal
(UHC 75th %ile)
Score through Jan fy10
95
90
85
80
75
70
65
60
55
50
BCMA
BPG
BPP
Brookline
Brookside
HC
FCP
Foxborough Jen Center
Newton
Corner
SJP HC
Spanish
Clinic
WHC
PC Total
• Cheerfulness of practice
• Cleanliness of practice
• Overall rating of care received during visit
• Likelihood of recommending practice to others
27
BWH Primary Care ED Utilization (Category: Transitions of Care)
Between April and December 2010, out of the 11,354 ED visits by BWH Primary Care patients, 3139 (27.6%) of
these visits were classified as “Low-Acuity” by the ED clinician performing the triage (ESI rating of 4 or 5).
Of the 3139 Low Acuity ED visits by a BWH Primary Care patient, 1312 of these visits occurred while the
patients’ Primary Care Physician’s office was open. This represented 11.6% of all BWH Primary Care ED visits to
the BWH ED, FH ED, and NWH ED.
The chart below shows the percentages of Low Acuity ED visits and Low Acuity ED visits that occurred while each
site was open, relative to each site’s total ED visits.
35%
Low Acuity
32.4%
31.8%
29.7%
30%
29.8%
28.8%
26.6%
26.1%
25%
Low Acuity- Practice Open
31.3%
26.0%
25.6%
24.4%
24.8%
24.1%
24.7%
20%
13.5%
15%
11.2%
10%
13.2%
12.1%
14.7%
11.2%
11.2%
10.7%
8.7%
10.7%
12.1%
10.2%
9.5%
10.1%
5%
HC
W
ic
Cli
n
SJ
P
Sp
an
is h
NC
tal
To
JC
en
ts
Re
JC
Fa
JC
sid
cul
t
y
B
FX
P
FC
e
ksi
de
HC
Br
oo
kli
n
Br
oo
BP
P
BP
G
BC
M
A
0%
28
Leadership Training
(“Skills”)
• CAP
• Adaptive Leadership
• Lean
29
Sample – Gap to Goal Assessment (“Implementation”)
100%
90%
90%
80%
80%
70%
70%
60%
60%
50%
50%
40%
40%
30%
30%
20%
20%
10%
Categories:
MD Ratings
100%
10%
0%
Patient access to
appointments
Frequency patient sees Functioning as a team
their own PCP or
and allowing everyone
member of the team
to practice at top of
license
Use of lists identifying Ask for, and use, patient
patients due for
feedback
preventive screenings
and chronic disease
management
Our practice’s leadership has clearly
articulated a vision of the patientcentered, team-based care model
90%
90%
80%
80%
70%
70%
60%
60%
50%
50%
40%
40%
30%
20%
10%
10%
0%
Patient access to
appointments
Frequency patient sees Functioning as a team
their own PCP or
and allowing everyone
member of the team
to practice at top of
license
Use of lists identifying Ask for, and use, patient
patients due for
feedback
preventive screenings
and chronic disease
management
- Continuity
- Team
- Prevention
Our practice’s leadership has clearly
Our practice has the capacity to make
articulated the reason for the change changes that might be required to deliver
towards the patient-centered, team- patient-centered, team-based care, every
based care model
day to every patient
Staff Ratings
100%
20%
- Access
0%
100%
30%
Practice skills:
0%
Our practice’s leadership has clearly
articulated a vision of the patientcentered, team-based care model
Our practice’s leadership has clearly
Our practice has the capacity to make
articulated the reason for the change changes that might be required to deliver
towards the patient-centered, team- patient-centered, team-based care, every
based care model
day to every patient
- Pt
engagement
Leadership
assessment:
- Understand
the vision
- Understand
the need
Works Well
Real Problem
Strongly Agree
Somewhat Disagree
Not a Problem
Totally Broken
Somewhat Agree
Strongly Disagree
Small Problem
N/A
- Practice can
make the
changes
Source: focus group
30
Organizing for Phase 2
• Continue to move toward fully-functional teams and
the infrastructure to support them
• PCMH Recognition Process – Primed Status
• Building the Medical Neighborhood
• Building the Infrastructure for Population
Management (CPM)
• Transitioning metrics to an evolving, multistakeholder environment
• Remain mindful of the challenges (cultural
resistance, residual variance, change fatigue,
balancing transformational and daily work)
31
PCMH Recognition: Primed Status to NCQA
A Partners Strategic Imperative
•
Access
•
Coordination of care
•
Team-based care
•
Role of medical home
•
Care management
•
•
•
Self-care management with community resources/referrals
Identify/address population needs/risks
Quality improvement
– Evening/weekend hours, agreement with facility for after-hours care
– Information to/from specialists/facilities (ie post acute)/patient, update care plan
– Defined roles and responsibilities, training, communication
– Discuss roles/expectations for medical home and for patients
– Pre-visit planning, care planning during visit, patient self-care, point of care
reminders
– Medication management
– Include mental health/substance abuse/behaviors affecting health
– Performance measurement
– Patient experience
32
32
Why a Neighborhood?
• Care coordination central to delivering on the
promise of the PCMH (access, quality, cost)
• Chronically ill, often elderly, multiply co-morbid
patients a key focus for care coordination
• By definition, requires efficient, effective,
patient-centered, bi-directional work flows
between PCP’s, specialists
• High interest by specialists to develop pilots
What Do We Mean by ‘Medical
Neighborhood?’
•Set of agreements between PCP and specialty practices that
defines effective communication, coordination, and integration
•Structure and processes in place to ensure patient-centered
approach to collaboration:
– Appropriate and timely consultations, referrals, and testing
– Efficient and effective flow of information
– Determines responsibility in co-management situations
Adapted from ACP White Paper, 2010
American College of Physicians. The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered
Medical Home with Specialty/Subspecialty Practices. Philadelphia: American College of Physicians; 2010: Policy Paper.
34
Everybody Wins in the Medical Neighborhood
Patients
Physicians
BWHC

Prompt access when needed

Patient concerns are addressed quickly, they do not have to
navigate between fragmented silos

PCPs and specialists practice at the top of their license

Specialists see more patients that require their expertise and
action

Clearer expectations and better communication makes patient
care easier and more enjoyable

Patients stay within BWHC family and are not referred out

Reduced trend through fewer unnecessary referrals

Reduced trend through fewer unnecessary diagnostic tests related to
referrals and co-management
35
BWH Pilots Planned
Cardiology
• Discussions around dedicated Primary Care Practice Cardiology team,
available for education, referral triage, and referrals
Dermatology
• Enhanced access for PCP
• New referral email/phone line being introduced
• Clinicam (tool for pre-referral triage) is being discussed in Dermatology
Gastroenterology
• Discussions around standardized triage process, using consult team
(attending and PA) to triage curbsides and referrals
Orthopedics
• Discussions around standardized triage process, using physicians assistant
to field curbsides and determine appropriate next step
Rheumatology
• Discussions around standardized triage process, using consult team
(attending and fellow) to triage curbsides and referrals
Surgery
• Ongoing PCP-Surgeon workgroup, discussing referral triage using on-call
paging system
4 PCP Sites
• Plan to develop and pilot interventions with the sites above
Status of Proposal:
Ready to pilot
Need input
38