introduction (i)
DESCRIPTION
Understanding Medical Homes A European study funded by the Commonwealth Fund Marjan J Faber GE Voerman Baker R, Constantinidis A, De Lepeleire J, Eriksson T, Lilienkamp C Richard PTM Grol. Introduction (I). - PowerPoint PPT PresentationTRANSCRIPT
Understanding Medical HomesA European study funded by the Commonwealth Fund
Marjan J FaberGE VoermanBaker R, Constantinidis A,De Lepeleire J, Eriksson T, Lilienkamp CRichard PTM Grol
Introduction (I)• Concept introduced in the US 40 years ago, in order to face the care for children
with special health care needs [CSHCN] (Sia et al., 2004)
• Medical Home is defined as A place—a single source of all medical information about a patient
A partnership approach with families to provide primary health care that is
1) accessible 2) family centered
3) coordinated 4) comprehensive
5) continuous 6) compassionate
7) culturally effective(Sia et al., 2004)
Medical Home: domains
1. A personal physician (3)
2. Physician-directed medical practice (3)
3. Whole-person orientation (8)
4. Coordination/integrated care (5)
5. Quality and safety (8)
6. Improved access (6)
7. Payment (3)Source: Joint Principles of the Patient-Centered Medical Homes (2007)
Problem definition
– There is no research evidence on the characteristics of the MH in European primary care
– There is no evidence on whether care provided according to the MH is associated with patient population, practice, or healthcare system characteristics
– There is no evidence on best practice
Project goals
• To achieve consensus about the concept of MH• To describe and compare current (and desired) care provision according to the MH
concept in a number of (European) countries with strong primary care systems• To analyze the degree of care provided according to the MH concept in relation to
characteristics of patients, practices, and countries• To identify best practice for MH and the problems that are encountered in
organizing a MH
Part 1 of MH project: Literature review and expert consultation Part 2 of MH project: Instrument development Part 3 of MH project: Fieldwork Part 4 of MH project: Analysis, interpretation, and dissemination
Part 1
Literature review & expert consultation
Part 2
Instrument development
Instrument development
Requirements instruments: Short and simple to complete
Addressing corresponding elements between the 3 instruments when possible
Target # items Details
Patient 38 5 about patients’ health6 about socio-demographics27 about MH care
Professional 33 6 about socio-demographics27 about MH care
Practice 26
Part 3
Fieldwork
Fieldwork: 5 countries
Source: Starfield & Shi, Health Policy 2002
Low performing countries
High performing
countries
# included** BE* DK GER UK NETH
Practices & GPs n=151 21 35 36 34 26
Patients n= 5598
- Total
- with chronic condition
- with chronic condition & at least
one practice visit in last year
764
695
677
1132
905
890
1848
1848
1805
1210
976
965
1474
1302
1273
Overview of data collection
* Flemish practices only** Overall responsratio 35%
Practice characteristics
Practice characteristics
Practice BE DK GER UK NETH
Number of employees in practice (fte, mean) GPs other healthcare providers other employees
3.71.11.1
2.42.41.2
1.52.80.6
4.44.712.7
1.32.3--
Number of patients seen per week in practice 201 175 329 477 200
Number of home visits (relative to number of practice visits
0.35 0.01 0.07 0.04 0.05
Number of telephone consultations (relative to the number of practice visits)
0.94 0.75 0.33 0.13 0.44
IT performance
Practice BE DK GER UK NETH
Does your practice use a computerized medical record system? (% yes) 100 100 83 100 100
Do you use your computer to send electronic prescriptions directly to pharmacies? (% yes) 5 100 0 15 96
Does your medical record system allow ….. you to share your patients’ medical records
electronically with clinicians outside your practice (% yes)
.. you to access your patients’ medical records when you are outside the office? (% yes)
.. your patients to directly access their own medical records? (% yes)
35
45
0
6
71
91
22
36
0
47
3
3
63
59
0
Tracking
Practice BE DK GER UK NETH
Does your practice have a list of enrolled patients? (% yes) 95 97 17 94 85
Does your practice have a systematic approach for … … managing information regarding outgoing
requests? (% yes) … archiving incoming patient information in the
medical record? (% yes)… tracking patient test results that come in, to ensure
that the clinical and patient have been notified of test results? (% yes)
… reminding patients about preventive care that is due? (% yes)
30
90
65
15
6
3
14
43
42
89
61
44
91
97
88
100
67
100
100
44
Quality and safety
Practice BE DK GE UK NETH
Do GPs have access in the practice to guidelines? (% yes) PR_12
80 100 86 100 89
Do GPs have access in their practice to medical literature? (% yes) PR_13
85 83 58 79 83
Has the practice undertaken at least one clinical audit in the last 12 months? (% yes) PR_14
20 82 83 97 41
Does the practice produce an annual report? (% yes) PR_15
10 14 25 53 71
Does the practice have a patient complaint procedure? (% yes) PR_19
15 31 53 100 92
Improved access
Practice BE DK GER UK NETH
Separate phone number for emergency calls (% yes) 40 66 28 27 100
Booking interval for routine appointments (mean (sd))
16 (4) 14 (2) 13 (3) 10 (0) 10 (3)
Proportion of same-day appointment: >75% 95 46 61 85 36
Office hours (% yes) < 8 am > 18 pm weekend
309535
50926
318611
245929
000
Patient experiences
Patient characteristics (1)
Patients BE DK GER UK NETH
Age (mean (sd); yr) 68 (13) 66 (11) 64 (13) 65 (13) 64 (12)
Gender (% male) 47 49 43 46 44
Education (%)High school or lessSome collegeCollege degree or higher
513116
622117
74179
503516
513316
Income (%)Much above averageSomewhat above averageAverageSomewhat below averageMuch below average
621222031
1029311813
519152636
411193035
1122271724
Born in country (% yes) 94 98 90 94 94
Patient characteristics (2)
Patients BE DK GER UK NETH
Health status (%)Excellent / Very goodGoodFair / Poor
84745
263341
43066
183845
64054
Chronic condition (% yes) Asthma / COPD Diabetes mellitus Hypertension Cardiovascular diseases Anxiety Depression Cancer Arthritis
122246266102323
1429542347623
183059295131136
25334622710930
2137532047523
Number of conditions (% > 1) 48 42 59 50 48
Number of practice visits (% ≥ 5) 67 44 65 51 48
Personal physician
BE DK GE UK NETH
When you had a medical problem, did you usually consult the same GP? (% yes) PA_B1
98 87 94 74 89
Recourse & team management
Patients BE DK GE UK NETH
How often did you feel confident that your GP’s staff worked well as a team to provide care for you? PA_B9
% always% often% rarely/never
70228
77221
74233
66295
553313
Were responsibilities and divisions of tasks of the members within the general practice team clear? (% yes) PA_B10 98 97 96 94 94
Whole person orientation (1)How often did your GP …. BE DK GE UK NETH
…. show interest in your psychological wellbeing? PA_B5
% always% often% rarely/never
462516
423424
443521
453124
382438
…. show concern about you and your home circumstances? PA_B8
% always% often% rarely/never
592517
463123
343829
413029
372835
…. listen carefully to you? PA_B6% always% often
8016
7323
7521
7521
6933
…. explain things in a way you could understand? PA_B7
% always% often
8313
7423
7322
7423
7220
Whole person orientation (2)How often did your GP ….. BE DK GE UK NETH
…. involve you in decisions regarding your treatment plans? PA_B16
% always% often% rarely/never
79165
76195
65269
67239
662212
…. verify whether your expectations were met at the end of the consultation? PA_B17
% always% often% rarely% never
602686
623053
30271825
49301210
42291812
Whole-person orientation (3)How often did your GP … BE DK GE UK NETH
… encourage you to manage aspect of your condition yourself , by giving you a written plan or instructions to help you manage your own care at home? PA_B20
% always% often% rarely% never
5925115
28361224
32321422
29341225
27322120
…. give you easy to understand advice on how to prevent diseases and how to improve your health? PA_B21
% always% often% rarely/never
572915
433917
414217
424018
353134
Coordination of care (1)
BE DK GE UK NETH
Has your GP organized and coordinated care provided by others for you (e.g. hospital care, prevention)? (% yes) PA_B2
87 76 85 81 82
Has your GP communicated with community care about your health problems or care needs when necessary? (% yes) PA_B3
60 13 21 37 49
Coordination of care (2)
Patients BE DK GE UK NETH
How often was your GP well informed about out-of-hours care provided to you by other doctors? PA_B14
% always% often% rarely% never
79164<1
6010327
6813910
532999
5828122
Was your GP well informed about the care you received by other health care providers and services? (% yes) PA_B4
98 89 94 89 93
How often was your GP well informed about laboratory results, radiology reports, and specialist consultations? PA_B15
% always% often% rarely
9082
86112
76194
76222
74195
Quality & Safety
Patient BE DK GE UK NETH
If you have had a complaint about your GP or practice, did you feel satisfied with the procedure? (% yes) PA_B19
90 49 78 66 83
How would you rate the quality you receive in your GP practice? % excellent% very good% good% fair / poor
3845152
3941174
2541304
4437154
2235348
Improved AccessPatients BE DK GE UK NETH
Did you have access to your medical records? (% yes) PA_B11
75 57 27 44 58
How often did your GP or the staff member responsible for the appointment schedule, do the best to give you an appointment that fitted your expectations? (% always) PA_B13
83 81 73 58 66
Was it possible for you to contact your GP by email? (% yes) PA_B22
55 80 30 38 53
In general, was it easy for you to contact your practice by phone during office hours? (% yes) PA_B23
98 97 93 90 82
When you phoned the practice out of hours, were you given information about how to get care out of hours? (% yes) PA_B24
58 96 93 97 96
Did your GP practice have a website with information on, for instance, office hours and telephone numbers? (% yes) PA_B25
92 96 52 87 88
PaymentPatients BE DK GE UK NETH
In the past 2 years, did you have problems in visiting your GP because of costs? (% yes) PA_B26 5 1 5 2 1In the past 2 years, could you get primary care without spending any out-of-pocket costs for medical treatments or services? (% yes) PA_B27 24 87 79 90 84
GP’s experiences
Lessons learned
Domain Best practice Diver for best practice
(Practice organization) UK QoF
Personal physician All
Medical team Denmark, Germany Disease management programs
Whole person orientation Belgium
Coordination Belgium
Quality & Safety Belgium
Improved access Denmark
Payment Denmark, UK
As to Flanders (Belgium)
• Very satisfied patients
with high level
- home visits
- same day appointments (95%)
- Regular visits after 6 pm
- consultation in the weekend
- patient expectations are met
As to Flanders (Belgium)
but:
•Low level of– Clinical audit– Annual reports– Compliant procedure– Concertation with other professionals– Attachmen t guidelines– Preventive actions– Direct patient access to medical file
– High cost for patients
Special thanks to ...
• Richard Baker, Leichester, United Kingdom• Jan De Lepeleire, Leuven, Belgium• Antje Erler, Frankfurt, Germany• Tina Eriksson, Copenhagen, Denmark• Gerlienke Voerman, Jako Burgers & Richard Grol, Nijmegen,
the Netherlands
• Robin Osborn, Commonwealth Fund, New York, US
Additional analysis
• Non-response analysis
• Relation between patient experiences and characteristics of:– Patients– GP practices– Healthcare systems
• Relation between patient ratings and professional ratings for same item
• Include interviews with best practice GPs
AUS(n=1009)
CAN(n=3003)
GER(n=1407)
NETH(n=1557)
NZ(n=1000)
UK(n=1434)
US(n=2500)
The adult has a regular doctor or place of care (% yes) 96% 91% 94% 100% 95% 97% 90%
Doctor(s)/staff know important information about the patient’s medical history (% always or often)
85% 84% 93% 90% 87% 79% 82%
The place is easy to contact by phone during regular office hours (% yes)
86% 78% 66% 75% 88% 80% 81%
The doctor(s)/staff at the source of care help coordinate care received from other doctors or sources of care (% always or often)
70% 67% 67% 55% 70% 58% 69%
The adult has a medical home (% yes)
59% 48% 45% 47% 61% 47% 50%
Scoring across 7 countries on key-elementsfor a medical home (Schoen et al 2007)
AUS = Australia; CAN = Canada; GER = Germany; NETH = Netherlands; NZ = New-Zealand; UK = United Kingdom; US = United States.