The Medical HomeA 26 year experience

Internal Medicine Northwest1984-2010

David R Muňoz, MD, MPH, FACP, FABQAURP, CMD

The Medical Home

• Internal Medicine North West (IMNW) was a unique practice pioneering most of the concepts embodied in the current definition of the Medical Home, which provided care for complex internal medicine patients, which operated for 26 years between 1984 and 2010.

DEMOGRAPHICS

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GENDER COUNT

MALES 9682

FEMALES 17275

TOTAL 26957

The Medical Home Model 2007 Joint Definition

• Personal physician: "each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care."

• 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."

• 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."

• Care is coordinated and/or integrated: Care is coordinated and/or integrated between complex health care systems, for example across specialists, hospitals, home health agencies, and nursing homes, and also includes the patient’s loved ones and community-based services. This goal can be attained though the utilization of registries, health information technology and exchanges, ensuring patients receive culturally and linguistically appropriate care.[9]

Quality and Safety

– Partnerships between the patient, physicians and their family are an integral part of the medical home. Practices are encouraged to advocate for their patients and provide compassionate quality, patient-centered care

– Guide decision making based on evidence based medicine and with the use of decision-support tools

– Physician’s voluntary engagement in performance measurements to continuously gauge quality improvement

– Patients are involved in decision making and provide feedback to determine if their expectations are met

– Utilization of informational technology to ensure optimum patient care, performance measurement, patient education, and enhanced communication

– At the practice level, patients and their families participate in quality improvement activities.[9]

Enhanced access

• Care is available through open scheduling and extended hours and new options for patient services.[9][24]

• This may include telemetric monitoring• Includes Point of Service (POS) testing for

rapid results and detailed instructions

Requires Appropriate Funding• Payment must "appropriately recognize the added value

provided to patients who have a patient-centered medical home."

• Payment should reflect the time physician and non-physician staff spend doing patient-centered care management work outside the face-to-face visit

• Services involved with coordination of care should be paid for

• It should support measurement of quality and efficiency with the use and adoption of health information technology.[25]

Appropriate Funding Continued

– Enhanced communication should be supported– It should value the time physicians spend using

technology for the monitoring of clinical data– Payments for care management services should not

result in deduction in payments for face-to-face service

– Payment "should recognize case mix differences in the patient population being treated within the practice"

Appropriate Funding Continued

– It should allow physicians to share in the savings from reduced hospitalizations

– It should allow for additional compensation for achieving measurable and continuous quality improvements

How I came to be here

Transistions

• IMNW determined in 2009 that in order to continue to deliver its mission to deliver comprehensive, competent, coordinated care for complex older adults, it needed to integrate with a larger organization which could provide the basis for an Accountable Care Organization.

• We then sought out and executed the transition to the Franciscan Medical Group, a part of Franciscan Health Services, Catholic Health Initiatives.

Personell

• IMNW was comprised of 9 physicians all Board Certified Internists including 4 hospitalists, 3 rheumatologists, 3 geriatricians and 2 hospice/palliative care physicians. Some physicians were multi-board certified. In addition 2 physicians were Board Certified Quality Assurance Utilization Review Medicine Diplomats and AMDA Certified Medical Directors

• IMNW also had 2 nurse practitioners, one Geriatric and one Adult Medicine as well as a Masters trained Diabetic Educator

Legacy

• IMNW provided care in the outpatient, inpatient and skilled nursing facility settings for an active patient population of about 7,000 patients and over the course of its history IMNW served 25,000+ patients.

• IMNW operated the first Medicare Approved Comprehensive Outpatient Rehabilitation Facility (CORF) in Washington State 1986-1991

Inpatient Services

– IMNW provided inpatient services within the Franciscan Health System at St Joseph, St Clare, St Francis 1984-2009

– IMNW provided inpatient services within the MultiCare Health System at Tacoma General and Allenmore Hospitals 1984-2009

– Important because 60% of all our patients used both systems of care

Long Term Care

– IMNW provided Medical Direction and SNF care at: • Tacoma Lutheran Retirement Community• Franciscan Health Care Center• Franke Tobey Jones Home• Belair Rehab & Ventilator Care Center• Heartwood • University Place Care Center

– IMNW provided SNF care at an additional 10 SNF facilities and 5 Assisted Living Facilities

Extended Care Services

– IMNW provided care in coordination with Franciscan, MultiCare and Good Samaritan Hospices

– IMNW worked with more than 30 community and home health agencies

– IMNW provided chronic wound care at Franciscan Wound Care Center

Patient/Family Centered

• IMNW worked closely with its patients and their families

• IMNW experienced up to 5 generations of care for family members

• IMNW provided care for many generations who successively experienced aging

• IMNW’s longest surviving marriage William & Helen Bookwalter was 77 years

Point of Service Delivery

• IMNW pioneered the use of point of service (POS) testing including – Hematocrits– HBA1C– INR– LFT’s– Lipid panels

Cardiovascular Monitoring

• IMNW pioneered the use of extended in home monitoring in a clinical trails with CardioCare for patients with Diabetes and CHF

• Office based use of echocardiography and vascular studies in partnership with Cardiodynamics for its large populations with congestive heart failure, diabetes and metabolic syndrome

Diabetic Monitoring

• IMNW provided 24 hour glucose recording• IMNW provided Diabetic Education with our

own Masters Prepared Certified Diabetic Educator

• IMNW provided POS HBA1C and Lipid Monitoring

• IMNW provided comprehensive diabetic wound care

Clinical Research Department performed 80 clinical research trials during a 15 year timeframe.

– Clinical studies of Alzheimer’s Disease (SmithKline Beecham; Somerset; Parke-Davis; Novartis; Bayer and Zeneca)

– Clinical studies of Acute Ischemic CVA (Lorex; Bristol, Meyer, Squibb; ICOS)– · Clinical studies of Diabetes (Miles; Eli Lily)– · Clinical studies of Decubitus Ulcers (CIBA; Ethicon; Johnson & Johnson;

Daiichi)– · Clinical studies of infection, Pneumonia (Upjohn); Cellulitis, (Tap) and

Urinary Tract Infections– · Clinical studies in Hypertension (Merck; ICI) – · Clinical studies in Congestive Heart Failure (ICI; Eli Lilly)– · Clinical studies in Musculoskeletal Impairment (Merck; Purdue)– · Clinical studies in Urinary Incontinence (Lilly; Alza)

Electronic Health EHR & E-Rx

• IMNW maintained an electronic health care record throughout its 26 year existence, which is being abstracted into a comprehensive research data base.

• IMNW also pioneered the use of electronic prescriptions, with an early patent on a form of telephone/fax communication of our prescription data base” 7,426,476 System and method for automated prescription management

Clinical Analytics

• IMNW pioneered the use of Clinical Analytics using its substantial data base and those of PacLab & Laboratories Northwest to manage its patients with chronic disease

• Models were applied in both outpatient and SNF populations

• IMNW also operated for 5 years the first Comprehensive Outpatient Rehabilitation Center in Washington State– provided outpatient/home evaluation of appropriate

Medicare patients– Offered comprehensive physical, occupational, speech and

respiratory therapy, social services and clinical psychology. The reimbursement mechanism was lesser of cost or charges. (It ceased this operation in 1991 after Medicare determined that CMS did not have enough accountants to open the 60 page Cost Report and settle the $56,000 debt that was owed to IMNW for 2 years at no interest.)

Financial Challenges

• IMNW was 60% Medicare and 18% Medicaid based• Successfully weathered 2 Federal Government

shutdowns, the worse of which last from 10/27/1986 – 2/02/1987 during which it received no Medicare or Medicaid Funds

• Experienced 5 Washington State Government shutdowns resulting in no Medicaid payments for up to 3 months over the course of its 26 year history

The IMNW Experience

• A $ 25,000 payment for E-prescribing was received 8 months after the close of the calendar year and well over 1 year later

• No payment was received for EHR which we in fact maintained throughout our history

• IMNW suffered grievous financial adversity through repeated Federal and State budgetary mismanagement

WE ALL BECOME SOMEONE WE’VE NEVER BEEN BEFORE AND THEN SPEND THE NEXT PHASE OF OUR LIVES COMING TO GRIPS WITH IT

(1951 MGTD, which I purchased for $ 350 when I was 16, rebuilt it in high school, restored it in 2007 and still drive it)