The PCMH in

Action:

Successes,

Challenges and

Lessons Learned

Darren M. Schulte, MD, MPPEVP, Collaborative Care Solutions, Alere

Digital Medical Office of the Future ConferenceLas Vegas, NevadaSeptember 10, 2010

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The Promise of the PCMHBenefits

Potential to strengthen primary care

Better coordinate and integrate patient care, esp for chronic disease

mgmt

Effectively incorporate HIT and evidence based decision support/

tracking tools into the practice

Early (qualified) success

Quality gains, increased patient and provider satisfaction

Lessons

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Healthy Primary Care = Quality Care

Multiple studies conducted over last several decades in

many countries report that greater access to primary care

results in:

* Fewer ED visits and hospital admits;

* More preventative treatment

* Lower overall costs

as compared with specialist driven care

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But Primary Care Is Under Stress…

Over next 5-10 years, more patients will seek primary care

given demographic trends and insurance reform

Without structural and payment reforms to attract and

retain generalists, access to quality primary care will

continue to suffer

Despite near universal coverage in Mass. following 2006

reform initiative, 20% of adult residents reported difficulty

obtaining care in 2009.1Sources:

(1) Health Affairs 2010: 29:6. 1234-1241

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Joint Principles of a PCMHMajor generalist societies (ACP, AAFP, AAP, AOA)

adopted principles for a medical home

1. Personal physician

2. Physician directed medical practice

3. Whole person orientation

4. Integrated, coordinated care

5. Quality and safety emphasis

6. Enhanced access

7. Payment reform 5

NCQA PPC-PCMH Recognition Standards

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Landscape of PCMH Initiatives

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• 27 multi-stakeholder projects in 20 states

• Single commercial payer sponsored projects in an

additional 21 states

• Medicaid / CHIP sponsored projects in 38 states

• There are only 5 states without any PCMH initiatives

underway

From Principles to Practice…

PCMH demonstration initiatives Hospital admits ER visits Total savings per pt

Colorado Medical Home for Children - 18% NR $215

Geisinger Health - 15% NR NR

Group Health Cooperative* - 6% -29% No change (initial 18mo)

$10 pmpm (>21 mo)

Intermountain Health Care -4.8% No change $640

North Carolina (CCNC) -40% ** -16% $516

North Dakota (MeritCare & BCBS ND) -6% -24% $530

Vermont Blueprint for Health -11% -12% $215

Sources: D. Fields, et. al. Health Affairs 2010; 29(5): 819-826; Grumbach, et. al. The Outcome of Implementing a Patient

Centered Medical Home Interventions. PCPCC Publication. Aug 2009 ; Reid, et al. Health Affairs 2010; 29 (5): 835-843

Annual Outcomes for Major Medical Home Demonstrations

Notes: *Compared with a control group; ** Asthma patient only. NR = not reported.

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What Were the Essentials for Success?

Dedicated care coordinators

Expanded provider access

Effective health information technology

• track patient issues, goals, recommended care

• predictive modeling, risk profiling, decision support

• performance measurement

Meaningful incentive payments

• Hybrid models – FFS plus coordination fees +/- performance-

Source: D. Fields, et. al. Health Affairs 2010;

29(5): 819-826

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Group Health Experience1

GHC piloted medical home pilot at Seattle in 2006

(total of 9,200 pts)

Reduced average physician panel size by ~25%

Hired more clinical and ancillary staff

Made greater use of virtual medicine, patient outreach

and chronic care mgmt techniques10

Group Health Experience (cont’d)

Results after 12 months…

• Improved patient satisfaction and access

• Reduced provider burnout

Positive experience based upon:

• Primary care investment for optimal staffing ratios

• Staff training and office workflow redesign

• Strong leadership and change management

• Use of patient-centric electronic records 11

It’s Harder than It Looks…A successful medical home will require:1

Physicians to work within (and lead) care teams

Expanded focus from one patient at a time to proactive practice panel

management

New practice organization and care delivery models

Active use of evidence-based decision-support, clinical registries and

information technology

Sources

(1) Ann Fam Med 2009;7:254-260.

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…And Physicians Aren’t Trained for This

Care team leadership

Continuous quality improvement

Population health management

Health coaching and education

Behavior change approaches

Patient self management skill building

Patient care goals and issue tracking & monitoring

Community resource integration13

Physicians & Coaches - Reinforcing Roles

Skill Set Physicians & Nurses* Health Coaches*

Provide Information Good Fair to Good

Stimulate Motivation Poor Good

Enhance Behavioral Skills Poor Good

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• Physicians have perceived their job to offer health advice and treat disease, not

motivate and change behavior

• Coaches are trained and expected to educate, build motivation and skills, and

provide support in order to help individuals achieve their goals

• Working together, each at the “top of their license”, clinicians and coaches can be

highly complementary and synergistic

* On average

Source:

Adapted from Gordon Norman, MD. Healthcare

Unbound Presentation, July 2010

Lessons from the National Demonstration

Project

Change is hard

• Integration of new roles, and responsibility into new

coordinated practice models with HIT adoption

• There is no simple “plug and play” technology focused

approach

Relationships matter

• Culture of teamwork and trust is critical to sustaining change

• Physicians must become team-focused

Leadership is key 15

It Takes a Village…Medical homes are not enough

without integration within a larger medical neighborhood

Care fragmentation between generalists and specialists will

mitigate PCMH gains

Most successful PCMH initiatives to date operate within an

integrated delivery network

Keys to success -- Information sharing, accepted

performance standards and incentives, and broad

accountability1

Source: N. Eng J Med 2008. 359(12): 1202-1205

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PatientCentered Care

Collaboration Opportunities

Smaller (and larger) practices will need assistance to

realize truly patient-centric care within a panel

PCMH providers who choose capable partners to provide

integrated support services and health information

connectivity will likely fare better than those who elect to

build it all themselves

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Technology Framework for the Medical Home

Steve Adams

What is a Medical Home?

• A model for care provided by physician practices that seeks to

strengthen the physician-patient relationship

• Replaces episodic care, based on illness and patient

complaints, with coordinated care, and a long-term, healing

relationship

• “Each patient has an ongoing relationship with a personal

physician who leads a team that takes collective responsibility

for patient care.”

• When needed, that physician arranges for appropriate care

with other qualified physicians

• Emphasizes enhanced care through open scheduling,

expanded hours, and communication between patients and

physicians

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PCMH Workflow

Practice must focus on individual and population level care

management.

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Functional Requirements

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Technology to Support PCMH

Practices may need to combine technology solutions

to meet all PCMH requirements.

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Meet Robert Amber

• Multiple comorbidities:

–Asthma

–Diabetes

–Hypertension

• His physician, Joseph

Barclay, MD, has made his

practice a Medical Home

• Dr. Barclay’s practice is part

of an IPA, where all the

practices participate in a

common care coordination

management platform

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Care Team

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Care Notes

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Messaging

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Messaging: Test Results

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Connected Clinical Registry

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Health Logs

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Summary

•The PCMH model requires care coordination &

interaction with an extended care team (not just the

physician)

•Solutions exist today to make PCMH work within a

practice

•Technology is one component of becoming a PCMH

practice – implementing the way the practice does

business is equally important

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