c1 primary care21st century final presentation
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TRANSCRIPT
Primary Care in the 21 st Century:
The New Specialty in Health Care
IHI 10 th Annual Summit on Redesigning the Clinical Office Practice March 24, 2009
Jack Cochran, MD, FACS Executive Director The Permanente Federation
510-271-4620 [email protected]
Learning Objectives
Participants will be able to:
° Describe how the broken health care system
has altered the quality of care in the United States
° Describe how the proliferation of sources of
medical information has changed the doctor- patient relationship
° Explain why Primary Care is central to
achieving high quality, affordable, patient- centered care and identify the elements essential for optimizing the Primary Care experience
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1
"Our greatest
responsibility
is to be good
ancestors."
Jonas Salk
3
Critical Confluence
° Affordability
° Nursing and other health care worker shortages
° Supply and sustainability of primary care physicians
° More patient focus/inclusion
° Essential major investments in technology and systems (including EMRs)
° Government and public policy probing for answers
° Baby Boomers entering Medicare
° Worst economic crisis in decades
Keys to solutions
will be health care
led by clinicians,
integrated with
functional IT
systems, and
staffed with
innovative,
enthusiastic,
computer-enabled
health care teams.
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Can We AFFORD Not to Lead?
100%
Cumulative Changes in Premiums, Inflation, & Earnings, 2000-2006
87% Health Insurance
Premiums
80%
60%
40%
20%
20%
Worker's Earnings
Overall Inflation 18%
0%
2000 2001 2002 2003 2004 2005 2006
5
International Comparison of Spending on Health 1980-2004
Total expenditures on health as percent ofGDP
7000
6000
Average spending on health per capita ($US PPP)
United States Germany Canada France Australia United Kingdom
16
14
12 5000
10
4000
8
3000
6
2000 4
1000 2
United States Germany Canada France Australia United Kingdom
0
19 80
19 82
19 84
19 86
19 88
19 90
19 92
19 94
19 96
19 98
20 00
20 02
20 04
0
19 80
19 82
19 84
19 86
19 88
19 90
19 92
19 94
19 96
19 98
20 00
20 02
20 04
Data: OECD Health Data 2005 and 2006.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006. 6
3
Six Nation Rankings on Health System Performance
Overall ranking
Quality care
Right Care
Safe Care
Coordinated Care
Patient-Centred Care
Access
Efficiency
Equity
Healthy Lives
Source: Commonwealth Fund (2007)
AUS
3.5
4
5
4
3
3
3
4
2
1
CAN
5
6
6
5
6
6
5
5
5
3
GER
2
2.5
3
1
4
2
1
3
4
2
NZ
3.5
2.5
4
3
2
1
2
2
3
4.5
UK
1
1
2
2
1
4
4
1
1
4.5
US
6
5
1
6
5
5
6
6
6
6
7
The Four Parts of the Quality Gap
° Overuse
° Underuse
° Misuse/Errors
° Waste
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4
Closing the Gap US data collated by Professor Bill Runciman, President,
Australian Patient Safety
Foundation from McGlynn et al;
NEJM 2006 Vol 348; p2635-45
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Dwindling Numbers
1997
2006
# US grads entering family medicine
residency
2340
1132
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5
Dwindling Numbers
Career Choices of Third-Year Internal Medical
Residents
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Uninsured
The statistics have
changed a little.
Partially Insured
The stories have changed a lot.
Numbers of uninsured continue to grow.
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Change
"The committee is confident that Americans can have a health care system of the quality they
need, want, and deserve. But we are also
confident that this higher level of quality cannot
be achieved by further stressing current
systems of care. The current care systems
cannot do the job. Trying harder will not work.
Changing systems of care will."
Crossing the Quality Chasm, IOM
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IOM's Six Major Challenges
"Organizations will need to negotiate successfully six major challenges."
° Redesigned care processes based on best evidence
° Effective use of information technology
° Knowledge and skills management
° Development of effective teams
° Coordination of care across conditions, services, and
settings
° Use of performance and outcomes measurement for
continuous improvement and accountability
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Crossing the Chasm to
the Medical Home
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A House is Not a Home
Picker Institute Eight Dimensions of Patient-centered Care
¢ Respect for the patient's values, preferences, and expressed needs
¢ Access to care
¢ Emotional support to relieve fear and anxiety
¢ Physical comfort
¢ Involvement of family and friends
¢ Coordination of care
¢ Continuity and secure transition between health
care settings
¢ Information and education
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The Old Model of Information Flow
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What Is a Pati nt to Do with This The New Model of Abundance of Information? Inform tion Flow
Graphic representing media
Graphic representing alternative practitioners (e.g. acupuncturist)
?
Graphic representing medical Web sites (WebMD?)
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The Future is Here
Marcus Welby, MD
"Marcia Welbyte," MD
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Patients Need a Trusted Partner
Graphic representing alternative practitioners (e.g. acupuncturist)
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Essential Roles of Health Care Teams and Clinicians
Healer
Leader
Partner
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Patients Need a Partner to Guide Them Through the Gaps
Even if you can't take care of the problem, be sure you still take care of the patient.
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We have been making Specialty Care more primary.
We need to make Primary Care more special.
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Primary Care is essential to:
° Maintain trusted, human connectivity in the patient's chaotic, complex world
° Manage and coordinate care
° Make care more affordable
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Why a Patient Centered Primary Care Practice?
Research demonstrates the value of having regular access to preventive and primary care
¢ Higher quality of care
¢ Higher patient satisfaction
¢ Reduced health care disparities
¢ Lower per person cost
ß
ß
ß
Lower emergency room utilization
Fewer hospital admissions
Fewer unnecessary tests and procedures
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The Value of Primary Care
¢ States with a greater ratio of generalist physicians to population had higher quality and lower costs
¢ States with a greater ratio of specialist physicians to population had lower quality and higher costs
"Medicare Spending, The Physician Workforce,
And Beneficiaries' Quality Of Care"
Baicker and Chandra
Health Affairs Web Exclusive. April 7, 2004.
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The Value of Primary Care
The stronger a country's primary care system, the lower the rates of all- cause mortality, all-cause premature mortality, and cause-specific premature mortality...
"Contribution of Primary Care to Health Systems and Health" Macinko, J., B. Starfield, and L. Shi
The Millbank Quarterly, Vol. 83, No. 3, 2005
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How Do We Leverage Primary Care Physicians and Teams?
Keys to making primary care more viable, desirable, and sustainable:
° Technology and tools
° Teams, including excellent
relationships with specialty care
° Compensation
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Technology and Tools
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Is Technology the Answer?
OO + NT = COO
It's not the box
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15
LO + NT = TO
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Even with the best of intentions
GAP
150,000 articles/month** 300,000 RCTs
20,000 biomedical journals 2,618 active performance measures
100,000 genetic tests over next few years
**Ann Intern Med 2001;135:309-12
200 MB capacity*
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Technology in the Hands of Physicians - Transforming Care
° Registries
° Prompts and Alerts
° Guideline Reminders
° Decision Support
° Predictive Modeling
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Yesterday's Care
Our patients are those who make appointments to see us
Patients' chief complaints or reasons for visit determines care
Care is determined by today's problem and time available today
Care varies by scheduled time and memory or skill of the doctor
Patients are responsible for coordinating their own care
I know I deliver high quality care because I'm well trained
Acute care is delivered in the next available appointment and walk-ins
It's up to the patient to tell us what happened to them
Clinic operations center on meeting the doctor's needs
Tomorrow's Care
Our patients are those who are in our panel
We systematically assess all our patients' health needs to plan care
Care is determined by a proactive plan to meet patient needs without visits
Care is standardized according to evidence-based guidelines
A prepared team of professionals coordinates all patients' care
We measure our quality and make rapid changes to improve it
Acute care is delivered by open access and non-visit contacts
We track tests & consultations, and follow-up after ED & hospital
A multidisciplinary team works at the top of our licenses to serve patients
Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma 34
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Teams (Including Excellent
Relationships with Specialty Care)
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The Power of Teams
Individuals collaborate and maximize their scope of practice to provide the best care for patients
¢ Physician
¢ Nurse
¢ Medical Assistant
¢ Pharmacist
¢ Behavioralist
¢ Specialist 36
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The Kaiser Permanente 21 st Century
Care Innovation Collaborative Model
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The KP Proactive Encounter Experience
Pre Encounter
Proactive Identification
• Identify missing labs, screening procedures, access management, kp.org status, etc.
• Provide member instructions prior to visit
• Contact member and document encounter in KP HealthConnect™
Office Encounter
Office Encounter Management
• Vital sign collection / documentation
• Identify and flag alerts for provider
• Room and prepare patient for necessary exams
• Pre-encounter follow-up
Proactive Office Support
• In-basket Management
Post Encounter
Immediate
• After visit summary, after care instructions, follow- up appointments, Health Ed materials, how to access info on kp.org
Future
• Follow-up contact and appointments per provider
POE success relies upon strong physician and staff partnerships based on clearly defined roles and responsibilities, team agreements, and improved communications. 38
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The Kaiser Permanente Collaborative Cardiac Care Service (CCCS)
Coordination among:
¢ Nursing team
¢ Cardiac rehabilitation program
¢ Pharmacy team
Patients enrolled in CCCS experienced a reduced incidence of all-cause mortality by 89%.
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Compensation
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"A key to the sustainability of primary care will be payment reform coupled with innovative quality measures"
"Primary Care: Too Important to Fail" David S. Meyers, MD, and Carolyn M. Clancy, MD
Annals of Internal Medicine February 17, 2009
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"Patients, specialists, and the entire health system need a healthy primary care base
Primary care practice is not viable without a substantial increase in the resources available to primary care physicians."
"The Primary Care-Specialty Income Gap: Why It Matters" Thomas Bodenhemier, MD, Robert A. Berenson, MD; and Paul Rudolf, MD, JD
Annals of Internal Medicine
February 20, 2007
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Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it's the only thing that ever has.
Margaret Mead
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Jack Cochran, MD, FACS
Executive Director The Permanente Federation
(510) 271-5886 fax: (510) 267-2194
email: [email protected]
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