A Discussion and / or a Research Presentation • Forming and joining the new Center for Community Health Integration (CHI) • Developing & evaluating a new measure of primary care 1
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Multilevel research & development to address the health effects of • Poverty, inequality, and an unprepared workforce, • Understanding, assessing and improving what provides value in primary health care, • The interaction of genetics, environment, social structures, and behavior, • An effective interface between health care and public health systems 3
CHI Center Faculty Secondary Appointment Primary Appointment • Terry Allan • Kurt Stange, Director • Daniela Calvetti • Heidi Gullett, Assoc Director • Claudia Coulton • Rob Fischer • Li Li • Ron Fry • Johnie Rose • Siran Koroukian • Others being recruited • Jim Lalumandier Adjunct Appointment • Masahiro (Mori) Morikawa • Bart Rog • Goutham Rao • Greg Brown • Nick Schiltz • Sue Flocke • Erkki Somersalo • Jim Werner • Others in process • Others - ? You? 4
Some initiatives in which we are involved • HIP-Cuyahoga - thousands of individuals and hundreds of organizations acting together to: • eliminate structural racism • integrate public health and health care • promote healthy eating/active living • reduce the burden of chronic illness • Center for Health Affairs & HIP-Cuyahoga - convening hospitals & health departments for joint community health needs assessment & improvement • Understanding, assessing improving value in primary care – measures that matter, simulation modeling of mechanisms & outcomes, ethnography • Population Cancer Analytics Shared Resource • NEOCase - Medicare +OCISS + geospatial analytics • Promoting Health Across Boundaries – www.PHAB.us • Bridges out of poverty interventions & collaborations • REACH- pragmatic approaches to nutrition, physical activity, community-clinical linkage • Education • Residency in Preventive Medicine & Public Health • Urban Health Pathway • Block 1 5
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Collective Impact • All participants have a common agenda for change including a shared understanding of the problem and a joint approach to solving it through agreed upon actions. • Collecting data and measuring results consistently across all the participants, ensuring shared measurement for alignment and accountability. • A plan of action that outlines and coordinates mutually reinforcing activities for each participant. • Open and continuous communication across many players to build trust, assure mutual objectives, and create common motivation. • A backbone organization(s) with staff and specific sets of skills to serve the entire initiative and coordinate participating organizations and agencies. Kania J, Kramer M. Collective impact. Stanford social innovation review; 2011. The Collective Impact Framework. www.collaborationforimpact.com/collective-impact 7
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Measuring What Matters in Family Medicine & Primary Care Rebecca Etz, PhD rebecca.etz@vcuhealth.org Associate Professor, Family Medicine and Population Health Co-Director, The Larry A. Green Center for the Advancement of Primary Care for the Public Good VCU School of Medicine Kurt C. Stange, MD, PhD kcs@case.edu Director, Center for Community Health Integration (CHI) Distinguished University Professor Dorothy Jones Weatherhead Professor of Medicine Professor of Family Medicine & Community Health, Population & Quantitative Health Sciences, Sociology, Oncology Case Western Reserve University Promoting Health Across Boundaries www.PHAB.us Editor, Annals of Family Medicine www.AnnFamMed.org Co-Director, The Larry A. Green Center Scholar, The Institute for Integrative Health https://tiih.org American Cancer Society Clinical Research Professor 9
Many thanks to • For doing the work • Martha M Gonzalez, BA • Jonathan P O’Neal, BA, • Sarah R Reves, FNP • Stephen J Zyzanski, PhD • For providing critical insights • Participants in the crowd sourcing • Participants in the Starfield III Summit • For planning next steps • Robert L Phillips 10
Overview • Primary Care Outcomes • Focusing on what is most important • Developing a new measure • Crowd sourcing • Starfield III Summit • Synthesis – 3 simple rules + a parsimonious set • Early reliability & validity assessment • Next steps that we hope may involve you! 11
Health Care Systems Based on Primary Care • Better population health • Lower cost • Less inequality • Better health care quality Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America's Health in a New Era. Washington D.C.: National Academy Press; 1996. Starfield B, Shi LY, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs W4-185 - W4-197, 2004. Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med . 2009;7:293-299 . 12
How Does Primary Care Produce these Results? 13
Principles of Primary Care • Accesibility as 1 st contact with health care • Accountability for large majority of healthcare needs (comprehensiveness) • Coordination & integration of care across settings, acute & chronic illnesses, mental health & prevention • Sustained partnership – relationships over time in a family & community context Starfield B. Primary Care. Balancing Health Needs, Services and Technology. New York: Oxford University Press, 1998. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America's Health in a New Era. Washington D.C.: National Academy Press; 1996. 1414 Stange KC, Nutting PA, Miller WL, et al. Defining and measuring the Patient-Centered Medical Home. J Gen Intern Med. 2010; 25(6): 601-612.
Principles of Family Medicine • Family physicians are committed to the person • rather than a particular body of knowledge, group of diseases • Family physicians seek to understand the context of the illness • Family physicians see every contact with the patient as an opportunity for prevention or health education • Family physicians view their practice as a population 15 Freeman T, McWhinney IR. McWhinney's textbook of family medicine. Fourth Ed. ed, 2016.
Principles of Family Medicine • Family physicians see themselves as part of a community-wide network of supportive and health care agencies • Ideally, family physicians share the same habitat as their patients • Family physicians see patients in their homes • Family physicians attach importance to the subjective aspects of medicine • Family physicians act as a manager of resources 16 Freeman T, McWhinney IR. McWhinney's textbook of family medicine. Fourth Ed. ed, 2016.
Measuring Primary Health Care • Good measures focus attention on what is important • Ideally, measures inform: • Understanding • Improvement • Support • (NOT punishment) Stange KC, Etz RS, Gullett H, et al. Metrics for assessing improvements in primary health care. Annu Rev Public Health. 2014;35:423-442. 17
Developing a New Measure of Primary Care • Problem with current measures • Too many measures, too burdensome • Focused on disease care and don’t recognize the higher level integrating, personalizing prioritizing functions • Not aligned with the foundations of primary care or the needs of patients, communities, systems • Starting over - • Begin by “crowd sourcing” - asking diverse stakeholders what is important to them about good quality care • Patients • Clinicians • Employers/Payers 18
Crowd sourcing - method • Open-ended online surveys asked: – “What is important in health care?” • Responses analyzed • What are people saying? • How does this compare to current measures? 19
Clinician Responses - what is important • N=425 (5374 responses) • Relationship, patient focus, integrated care and systemic support • 42% of what clinicians said was important did not fit with current measures 20
Patient Responses - what is important • N=325 (3571 responses) • Relationship, personalized attention, to assess care, communication • 72% overlap with what clinicians said was important 21
Employers/Payers Responses what is important • N=82 (807 responses) • Cost, access to care, happy employees • Only 46% overlap with what clinicians say is important 22
Crowd sourcing – Lessons Learned • Clinicians and patients think that a lot of the same things are important • Patients want more personalized attention • Clinicians don’t feel that what they do that is important is recognized or supported • Employers/payers focus on cost & employee experience • A large portion of what clinicians & patients think is important is missing from current measures • All groups consider systemic support & integration important 23
Starfield III Summit http://www.starfieldsummit.com/starfield3 24 (Measures & report available under “Resources” tab.)/
Starfield III Summit • 70 national & international primary care leaders • Met for 2.5 days • Individual, large and small group work • October 4-6, 2017 in Washington DC • Objectives: • Look at data to find what is important • Try to develop a simple measure http://www.starfieldsummit.com/starfield3/ 25 (Measures & report available under “Resources” tab.)
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