Is Your Hospital a Patient Centered Medical Home? Joseph E. - PDF document

Is Your Hospital a Patient Centered Medical Home? Joseph E. Scherger, MD, MPH We give you the care you want and need, how, when and where you want and need it Donald Berwick, MD 1

5 Domains of Hospital Care  Trauma and major acute illness such as heart attacks and strokes  Minor acute illness  Maternal and child care  Chronic illness care  Preventive services Patient Centered Medical Home Care Coordination By A Team Not Dependent on Visits 2

A Patient Centered Philosophy  Focus on relationships, especially the physician/patient relationship  Make the patient the center of care  Provide accessible, comprehensive, coordinated and continuous care  Make data understandable to the patient 5 Features of a PCMH  Comprehensive Care – meet a patient’s physical and mental healthcare needs as a team  Patient-centered Care – a partnership with deep empathy for the uniqueness of patients  Coordinated Care –across all elements of the healthcare system  Accessible services – minimizing delays and wait times  Quality and Safety 3

Vital Components to Achieving The Goals of a PCMH  Health Information Technology – able to store, manage and integrate patient information individually and as a population  Workforce – a team with the focus on meeting all patient needs  Finance – aligned with the goals of the PCMH. Prepayment and hybrid payment models with accountability for safety and quality 4 Transformations to a PCMH  Realize this is a marathon and takes time – a two year transformation process  Become information centered through robust technology with a patient portal to all records  Get patient feedback  Consider the patient experience in all locations 4

Physician Engagement is Critical  Connection with personal physicians is the key to success  Physician referral is the most powerful motivator  Integrated physician and self-care critical for the outcomes Taking Steps to a PCMH  Review and change operating principles  Select care coordinators  Seek recognition as a PCMH, e.g. NCQA and JCAHO  Communicate with patients 5

Accountable Care Organizations (ACOs) Systems that are accountable for the health of the population served by provided value driven health care - Committed to the Triple Aim The Triple Aim  Improve the health of the population being served  Improve the experience of receiving care  Provide cost effective care – the value equation – eliminate waste 6

The Triple Aim  Better Health  Better Care  Lower Cost Main Features of an ACO  Manage cost and quality across a diverse population with different payment systems  Sufficient infrastructure and management acumen to support comprehensive care  Clear organization mission and commitment to accountable population health care  Health Information Technology that enables the achievement of ACO goals 7

Transforming Concepts for Success  Care becomes continuous access rather than episodic  Care becomes proactive rather than reactive  Patients become activated for self- management  Care is delivered by highly organized teams Effective ACOs are accomplished through effective PCMHs throughout the health system 8

58 y/o female with obesity and diabetes comes in with symptoms of fatigue, insomnia and back pain. She has a 15 minute appointment HEDIS diabetes measures for this patient :  Percent with an annual retinal exam  Percent with one of more glycohemoglobin tests  Percent of those having glycohemoglobin tests showing a level of <8.5 percent (goal <7.0)  Percent with an annual screening test for microalbuminuria  Percent with two or more blood pressure checks per year  Percent of those with one or more blood pressure checks having a systolic BP <135 (goal <<130/80)  Percent with an annual lipid panel  Percent of those with an annual lipid panel showing an LDL level <130 mg/dL (goal << 100) Case con’t Other Diabetes Measures:  Flu vax  Pneumovax  Dental visit  Cardiac screening test?  Lab monitoring for side effects of meds  Annual foot exam  Baseline EKG? 9

Case con’t Cancer Screening needs:  Colon- needs colonoscopy (or 3 other types of screening)  Cervical- needs pap if last <1-3 years prior  Breast- needs annual mammogram Osteoporosis screening and prevention Depression Screening and Management Case con’t  General health issues:  Adult Td  Weight management  Advance Directives/DPOA  Culturally-sensitive care  Patient Education for Self Management  Tobacco Screen  Alcohol screen  Domestic violence screen  What About her fatigue, insomnia and back pain? 10

27% 26% Only 27% of hypertension Only 26% of people with diabetes have is adequately controlled. blood pressures well controlled. 25% 50% 50% of patients hospitalized with Only 25% of people with congestive heart failure (CHF) are depression receive treatment. readmitted within 90 days. The Time Problem  Time Needed for Chronic  10.6 hours a day for 2500 Illness Care patients  Time Needed for  7.4 hours a day Preventive Care  Time Needed for Acute  4.6 hours a day Care  Total face to face time for  22.6 hours/day 2500 patients Ann Fam Med 2005;3:209 Am J Pub Health 2003;93:635 11

The Patient’s Life  6000 hours a year awake  1350 hours a year making decisions important to diabetes  2 hours of episodic contact a year with the primary care physician and only urgent access between The Care Model http://www.improvingchroniccare.org Community Health System Resources and Policies Health Care Organization Self- Delivery Decision Clinical Management System Support Information Support Design Systems Informed, Prepared, Productive Activated Proactive Interactions Patient Practice Team Improved Outcomes 12

Patient Activation and Self Management are a New Frontier in Medicine Made Possible by the Information Age The Care Team Goes From Mandatory Caregiver to Advisor, Coach and Personal Resource 13

Give us control and we will use it, don’t and you will lose us Google Rule # 1 from What Would Google Do? Jeff Jarvis There is an inverse relationship between control and trust Google Rule # 2 14

Soon many patients will control and guide their care. The care team will inform, coach and advise, but not be in control Patient has a new diagnosis of Multiple Sclerosis. What is the most effective thing to do first? Ask her primary care physician to 1. coordinate the care of the disease? Get treated by a local neurologist? 2. Get treated by the region’s best expert in 3. MS? Connect with a team to receive 4. biopsychosocial care? Go to the internet and join the MS group in 5. Patients Like Me? 15

Do PCMH practices and becoming an ACO enhance the bottom line? 16