Transcript Intro to PCMH - Tulane University

THE PATIENTCENTERED MEDICAL
HOME
Sarat Raman, MD
Dept. of Family & Community Medicine
Tulane University School of Medicine
OBJECTIVES
 By the end of this session the learner will be able to:
 Discuss the need for change in the healthcare system of the US.
 Describe the seven principles of the patient-centered medical home
 Describe some of the proven benefits of the patient-centered
medical home
 Discuss the variety of locations, collaborative partners, clinic types
and health care settings that have successfully used the patient
centered medical home
IHI “TRIPLE AIM”
 “Work to improve site-specific care for individuals should
expand and thrive. In our view, however, the United States
will not achieve high-value health care unless improvement
initiatives pursue a broader system of linked goals. In the
aggregate, we call those goals the “Triple Aim”:
 improving the individual experience of care; [better
care]
 improving the health of populations; [better health]
 and reducing the per capita costs of care for populations.
[lower cost] “
Donald M. Berwick, Thomas W. Nolan and John Whittington The Triple Aim: Care, Health, And Cost. Health Affairs, 27, no.3 (2008):759-769
BETTER HEALTH
Ranking
Country
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


1
2
3
4
5
6
7
8
9
10
France
Italy
San Marino
Andorra
Malta
Singapore
Spain
Oman
Austria
Japan




36
37
38
39
Costa Rica
United States
Slovenia
Cuba
The World Health Report 2000 – Health systems: Improving performance
BETTER HEALTH
 Of 13 [industrialized] countries in a recent comparison,
the United States ranks an average of 12th (second
from the bottom) for 16 available health indicators
 13th (last) for low-birth-weight percentages
 13th for neonatal mortality and infant mortality overall
 11th for postneonatal mortality
 13th for years of potential life lost (excluding external causes)
 11th for life expectancy at 1 year for females, 12th for males
 10th for life expectancy at 15 years for females, 12th for males
 10th for life expectancy at 40 years for females, 9th for males
 7th for life expectancy at 65 years for females, 7th for males
 3rd for life expectancy at 80 years for females, 3rd for males
 10th for age-adjusted mortality
Starfield B. Is US Health Really the Best in the World?. JAMA. 2000;284(4):483-485.
TRAGEDY IN THE SKIES
# of passengers in a 747
Weeks in a year
Total
What if it happened every other day?
 23,400 * 3.5 = ???

= 81,900 deaths per year…
450
52
23,400
BETTER HEALTH
 “At least 44,000 people, and perhaps as many as 98,000 people, die in
hospitals each year as a result of medical errors that could have been
prevented, according to estimates from two major studies. Even using
the lower estimate, preventable medical errors in hospitals exceed
attributable deaths to such feared threats as motor-vehicle wrecks,
breast cancer, and AIDS.
To Err is Human: Building a Safer Health System, Institute of Medicine. Sept 1999.
DANGER WILL ROBINSON! DANGER!

US estimates of the combined effect of
errors and adverse effects that occur
because of iatrogenic damage not
associated with recognizable error include:
 12,000 deaths/year from unnecessary surgery
 7000 deaths/year from medication errors in hospitals
 20,000 deaths/year from other errors in hospitals
 80,000 deaths/year from nosocomial infections in
hospitals
 106,000 deaths/year from nonerror, adverse effects of
medications
 These total to 225,000 deaths per year from
iatrogenic causes.
Starfield B. Is US Health Really the Best in the World?. JAMA. 2000;284(4):483-485.
BETTER CARE
BETTER CARE
BETTER CARE
Timely Appt, Care and…
Urgent Appt
Routine Appt
Never/Sometimes
Usually
Always
Phone Response
Wait Time w/in 15min…
Rating of the Doctor
Recommend Doctor
0%
20% 40% 60% 80% 100%
Consumer Assessment of Healthcare Providers and Systems (CAHPS) program: 2012 Clinician & Group Survey Results
LOWER COSTS
Ranking
Country
Expenditure Per Capita
•
•
•
•
•
•
•
•
•
•
1
2
3
4
5
6
7
8
9
10
France
Italy
San Marino
Andorra
Malta
Singapore
Spain
Oman
Austria
Japan
4
11
21
23
37
37
24
62
6
13
•
•
•
•
36
37
38
39
Costa Rica
United States
Slovenia
Cuba
50
1
29
118
The World Health Report 2000 – Health systems: Improving performance
LOWER COSTS
Major components of the $3.5 trillion spent in fiscal 2010
http://www.factcheck.org/2011/07/fiscal-factcheck/
LOWER COSTS
http://www.marketwatch.com/health-care/reform/snapshot
LOWER COSTS
K. Davis, C. Schoen, S. Guterman,T. Shih, S. C. Schoenbaum, and I. Weinbaum,
Slowing the Growth of U.S. Health Care Expenditures:What Are the Options?,The Commonwealth Fund, January 2007
THE PATIENT-CENTERED MEDICAL HOME
 The Patient Centered Medical Home is a health care setting that
facilitates partnerships between individual patients, and their personal
physicians, and when appropriate, the patient’s family. Care is facilitated
by registries, information technology, health information exchange and
other means to assure that patients get the indicated care when and
where they need and want it in a culturally and linguistically appropriate
manner.
http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx
WHY OUTPATIENT?
A typical month of health care in the United States
N England Journal of Medicine 2001;344:2021-25]:
HISTORY OF THE PCMH
 1967 – AAP introduces the term “medical home”, which described a single source of
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medical information about a patient
1978 - WHO made the Alma Ata declaration describing the importance of primary
care. This also laid some of the basic tenets in language that is now used to describe
the PCMH
1990’s – IOM begins mentioning the “medical home”
2002 – The Future of Family Medicine Collaborative – “every American should have a
Personal Medical Home that serves as the focal point through which all individuals—
regardless of age, sex, race, or socioeconomic status—receive their acute, chronic, and
preventive medical care services.” – recognizing the importance of the Chronic Care
Model as a contributor to the PCMH
2006 – ACP developed “advanced medical home”
2006 – IBM and Patient Centered Primary Care Collaborative to promote the medical
home concept
HISTORY OF THE PCMH
2007 – Release of the Joint Principles of the Patient-
Centered Medical Home.
 American Academy of Family Physicians
 American Academy of Pediatrics
 American College of Physicians
 American Osteopathic Association
 Representing 333,000 physicians.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
HEALTH CARE ENDORSEMENTS
 American Academy of Hospice and
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Palliative Medicine
American Academy of Neurology
American College of Cardiology
American College of Chest Physicians
American College of Occupational and
Environmental Medicine
American College of Osteopathic
Family Physicians
American College of Osteopathic
Internists
American Geriatrics Society
http://www.pcpcc.net/content/specialist-health-endorsements
 American Medical Association
 American Medical Directors Association
 American Society of Addiction Medicine
 American Society of Clinical Oncology
 Association of Professors of Medicine
 Association of Program Directors in
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Internal Medicine
Clerkship Directors in Internal Medicine
Infectious Diseases Society of America
Society for Adolescent Medicine
Society of Critical Care Medicine
JOINT PRINCIPLES OF
THE PATIENT-CENTERED MEDICAL HOME
1.
2.
3.
4.
5.
6.
7.
Personal Physician
Physician Directed Medical Practice
Whole Person Orientation
Care is Coordinated and/or Integrated
Quality and Safety
Enhanced Access
Payment
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
JOINT PRINCIPLES OF
THE PATIENT-CENTERED MEDICAL HOME
Personal physician
 Each patient has an ongoing relationship with a personal
physician trained to provide first contact, continuous and
comprehensive care.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
JOINT PRINCIPLES OF
THE PATIENT-CENTERED MEDICAL HOME
Physician directed medical practice
 The personal physician leads a team of individuals at the
practice level who collectively take responsibility for the
ongoing care of patients.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
JOINT PRINCIPLES OF
THE PATIENT-CENTERED MEDICAL HOME
Whole person orientation
 The personal physician is responsible for providing for all
the patient’s health care needs or taking responsibility
for appropriately arranging care with other qualified
professionals. This includes care for all stages of life;
acute care; chronic care; preventive services; and end of
life care.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
JOINT PRINCIPLES OF
THE PATIENT-CENTERED MEDICAL HOME
Care is coordinated and/or integrated across all
elements of the complex health care system (e.g., subspecialty care,
hospitals, home health agencies, nursing homes) and the patient’s
community (e.g., family, public and private community-based services).
Care is facilitated by registries, information technology, health
information exchange and other means to assure that patients get the
indicated care when and where they need and want it in a culturally and
linguistically appropriate manner.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
JOINT PRINCIPLES OF
THE PATIENT-CENTERED MEDICAL HOME
Quality and safety
are hallmarks of the medical home:
 Practices advocate for their patients to support the attainment of optimal, patient-centered
outcomes that are defined by a care planning process driven by a compassionate, robust
partnership between physicians, patients, and the patient’s family.
 Evidence-based medicine and clinical decision-support tools guide decision making
 Physicians in the practice accept accountability for continuous quality improvement
through voluntary engagement in performance measurement and improvement.
 Patients actively participate in decision-making and feedback is sought to ensure patients’
expectations are being met
 Information technology is utilized appropriately to support optimal patient care,
performance measurement, patient education, and enhanced communication
 Practices go through a voluntary recognition process by an appropriate non-governmental
entity to demonstrate that they have the capabilities to provide patient centered services
consistent with the medical home model.
 Patients and families participate in quality improvement activities at the practice level.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
JOINT PRINCIPLES OF
THE PATIENT-CENTERED MEDICAL HOME
Enhanced access to care is available through systems such as
open scheduling, expanded hours and new options for communication
between patients, their personal physician, and practice staff.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
JOINT PRINCIPLES OF
THE PATIENT-CENTERED MEDICAL HOME
 Payment appropriately recognizes the added value provided to patients who have a patient-centered
medical home. The payment structure should be based on the following framework:
 It should reflect the value of physician and non-physician staff patient-centered care management work
that falls outside of the face-to-face visit.
 It should pay for services associated with coordination of care both within a given practice and between
consultants, ancillary providers, and community resources.
 It should support adoption and use of health information technology for quality improvement;
 It should support provision of enhanced communication access such as secure e-mail and telephone
consultation;
 It should recognize the value of physician work associated with remote monitoring of clinical data using
technology.
 It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care
management services that fall outside of the face-to-face visit, as described above, should not result in a
reduction in the payments for face-to-face visits).
 It should recognize case mix differences in the patient population being treated within the practice.
 It should allow physicians to share in savings from reduced hospitalizations associated with physicianguided care management in the office setting.
 It should allow for additional payments for achieving measurable and continuous quality improvements.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
IHI “TRIPLE AIM”
 “Work to improve site-specific care for individuals should
expand and thrive. In our view, however, the United States
will not achieve high-value health care unless improvement
initiatives pursue a broader system of linked goals. In the
aggregate, we call those goals the “Triple Aim”:
 improving the individual experience of care; [better
care]
 improving the health of populations; [better health]
 and reducing the per capita costs of care for populations.
[lower cost] “
Donald M. Berwick, Thomas W. Nolan and John Whittington The Triple Aim: Care, Health, And Cost. Health Affairs, 27, no.3 (2008):759-769
PCMH OUTCOMES
Better Health
 2010 study showed improvement in condition-specific
outcomes (measures of the quality of care from the
Ambulatory Care Quality Alliance (ACQA) Starter Set),
measures of delivery of clinical preventive services and
chronic disease care.
 ACQA scores improved 8.3%-9.1%
 Chronic Care Scores improved 5.0%-5.2%
 Improved Prevention Scores (although not statistically
significant)
Jaén, C., Ferrer, R. et al., Patient Outcomes at 26 Months in the Patient-Centered Medical Home
National Demonstration Project. Ann Fam Med 2010;8(Suppl 1):s57-s67.
PCMH OUTCOMES
Better Health
 Air Force: 77% of diabetic patients improved glycemic
control
 MN: Health Partners: 129% increase in optimal diabetes
care; 48% in heart disease care
 NJ: BCBS of NJ: 8% improvement in HgbA1c
 NC: Community Care of North Carolina: 21% increase
in asthma staging; 112% increase in influenza inoculations
Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home:
A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.
PCMH OUTCOMES
Better Health
 OH: Humana Queen City Physicians: 22% decrease in
uncontrolled HTN
 OR: CareOregon Medicaid and Dual Eligibles: 65% with
controlled A1c vs 45% pre-PCMH
 PA: Geisinger Health System Proven-Health Navigator
PCMH Model: improved quality: 74% preventive Care,
22% Coronary Artery Care; 34.5 % Diabetes Care
Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home:
A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.
PCMH OUTCOMES
Better Health
 PA: Independence Blue Cross – Pennsylvania Chronic
Care Initiative: in Diabetics: 49& improvement in A1c;
25% increase in BP control; 27% increase in cholesterol
control
 TX:WellMed, Inc: LDL control from 51% to 95% in heart
disease patients; mammography from 19% to 40%; colon
cancer screening from 11% to 50%
Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home:
A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.
PCMH OUTCOMES
Better Care
 2010 study showed no improvement in patient related
outcomes including ratings of the 4 pillars of primary
care (easy access to first-contact care, comprehensive
care, coordination of care, and personal relationship
over time), global practice experience, patient
empowerment, and self-rated health status.
Jaén, C., Ferrer, R. et al., Patient Outcomes at 26 Months in the Patient-Centered Medical Home
National Demonstration Project. Ann Fam Med 2010;8(Suppl 1):s57-s67.
PCMH OUTCOMES
 Better Care
 CO: Colorado Medicaid and SCHIP: Increased well-care visits
54%->73%
 FL: Capital Health Plan: 250% increase in primary care visits
 MA: Pediatric Alliance for Coordinated Care: 60.9% reported
increased ease to communicate with MD, 61.4% reported it
was easier to get early medical care
 MI: BCBS of Michigan: 60% better access to care (25% in non-
participating sites)
Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home:
A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.
PCMH OUTCOMES
 Better Care
 MN: Healthpartners: reduced appointment wait time by 350% (26
days to 1 day)
 ND: BCBS of North Dakota-MediQHome Quality Program: 24%
reduction in ED visits, 30%reduction in ED visits in chronic disease
patients
 NY: Capital District Physicians’ Health Plan: 24% lower hospital
admissions
 OK: Oklahoma Medicaid: 8% increase in “always getting treatment
quickly”
 PA: PinnacleHealth: 0% 30-day readmission rate vs 10-20% for nonPCMH
Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home:
A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.
PCMH OUTCOMES
Better Care
 Veterans Health Administration and VA Midwest
Healthcare Network: 8% reduction urgent care visits, 4%
reduction in acute admission rates, 27% reduction in
admissions for chronic disease patients
 WA: Regence Blue Shield (Intensive Outpatient Care
Program with Boeing) 2012: 65% reduced patient
reported missed workdays
 WA: Group Health of Washington: 83% of patient calls
resolved on first (vs. 0% pre-PCMH)
Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home:
A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.
PCMH OUTCOMES
Lower Costs
 CA: BCBS of California ACO Pilot: %15.5 million overall
health care cost savings
 CO: Colorado Medicaid and SCHIP: $215 lower PMPY
 Idaho: BCBS of Idaho Health Service: $1 million
reduction in single year claims
 MD: CareFirst BCBS: 4.2% reduction in expected health
care costs for patients in 60% of practices participating
for 6+ months.; $40 million savings in 2011.
Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home:
A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.
PCMH OUTCOMES
Lower Costs
 NC: Community Care of North Carolina: $1.145 billion
savings between 2006-2010; 11% lower pharmacy costs
 OR: CareOregon Medicaid and Dual Eligibles: 9% lower
PMPM costs
 SC: BCBS of South Carolina: 6.5% lower total PMPM
medical and pharmacy costs
 TX: BCBS of Texas: $1.2 million health care costs savings
Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home:
A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.
PCMH OUTCOMES
Provider Satisfaction
 WA: Group Health of Washington: Less emotional
exhaustion (10% vs 30% in control group)
Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home:
A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.
OBJECTIVES
 By the end of this session the learner will be able to:
 Discuss the need for change in the healthcare system of the US.
 Describe the seven principles of the patient-centered medical home
 Describe some of the proven benefits of the patient-centered
medical home
 Discuss the variety of locations, collaborative partners, clinic types
and health care settings that have successfully used the patient
centered medical home
BIBLIOGRAPHY
 Donald M. Berwick, Thomas W. Nolan and John Whittington The Triple Aim: Care, Health, And Cost. Health
Affairs, 27, no.3 (2008):759-769
 The World Health Report 2000 – Health systems: Improving performance
 Starfield B. Is US Health Really the Best in the World?. JAMA. 2000;284(4):483-485.
 To Err is Human: Building a Safer Health System, Institute of Medicine. Sept 1999.
 Consumer Assessment of Healthcare Providers and Systems (CAHPS) program: 2012 Clinician & Group
Survey Results
 http://www.factcheck.org/2011/07/fiscal-factcheck/
 http://www.marketwatch.com/health-care/reform/snapshot
 K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum. Slowing the Growth of U.S. Health
Care Expenditures:What Are the Options?,The Commonwealth Fund, January 2007
 http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx
 N England Journal of Medicine 2001;344:2021-25]:
BIBLIOGRAPHY
 http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
 http://www.pcpcc.net/content/specialist-health-endorsements
 Nielsen, M., Langner, B., et al. Benefits of Implementing the Primary Care Patient-Centered Medical
Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative. 2012.
 The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational
Change. Robert Graham Center for Policy Studies in Family Medicine and Primary Care. November
2007.
 Starfield, B., Shi, L., and Macinko, J., Contribution of Primary Care to Health Systems and Health. The
Milbank Quarterly,Vol. 83, No. 3, 2005 (pp.457-502).
 Jaén, C., Ferrer, R. et al., Patient Outcomes at 26 Months in the Patient-Centered Medical Home
National Demonstration Project. Ann Fam Med 2010;8(Suppl 1):s57-s67.
QUESTIONS?
The slides from this presentation and some of the source material are
available at the Tulane Department of Family and Community Medicine.
http://tulane.edu/som/departments/fammed/seminars.cfm