The Secret Sauce of a Successful Medical Home Joseph E. Scherger, MD, MPH AAFP/STFM Conference on Practice Improvement November 5-8, 2009

What Is a Patient-Centered Medical Home? A Patient-Centered Medical Home (PCMH) is a model for care provided by physician practices that seeks to strengthen the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship (NCQA). A Patient-Centered Medical Home (PCMH) is a model for care provided by physician practices that seeks to strengthen the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship (NCQA). Adapted from Joint Principles of the Patient-Centered Medical Home, March Available at: 07medicalhome.pdf.

The Holy Grail of Redesign Cost Reduction Cost Reduction Quality Improvement Quality Improvement Service Improvement Service Improvement

The Secret Sauce for Successful Redesign Care becomes continuous access rather than episodic Care becomes continuous access rather than episodic Care becomes proactive rather than reactive Care becomes proactive rather than reactive Patients become activated for self- management Patients become activated for self- management

The New Millennium Quality Chasm Exposed Quality Chasm Exposed Cost Inflation Resumes Cost Inflation Resumes Consumer Driven Health Care Consumer Driven Health Care Primary Care Under Stress Primary Care Under Stress The Decade of Health Information Technology and Transformation in the Process of Care The Decade of Health Information Technology and Transformation in the Process of Care

Current Clinical Practice Current Clinical Practice Based on an Acute Care Model and Physician Centered Care Based on an Acute Care Model and Physician Centered Care Does not work well for Prevention and Chronic Illness management Does not work well for Prevention and Chronic Illness management Brief episodic visits must be part of a continuous system of care Brief episodic visits must be part of a continuous system of care Longer visits needed for complex patients Longer visits needed for complex patients Multidisciplinary teams working as a quality system of care Multidisciplinary teams working as a quality system of care

A Growing Problem “I can’t do what I came to do – help people through a variety of difficult problems. I don’t have the time to do the job right.” “I can’t do what I came to do – help people through a variety of difficult problems. I don’t have the time to do the job right.” “We are not doing a good job, and it’s not our fault. Our care model is faulty.” “We are not doing a good job, and it’s not our fault. Our care model is faulty.”

Outcomes in Hypertension NHANES JNC VI OlmsteadCounty Aware 73% 73% 68% 68% 61% 61% Treated 55% 55% 54% 54% 45% 45% Controlled 29% 29% 27% 27% 17% 17%

Only 27% of hypertension is adequately controlled. 27% Only 26% of people with diabetes have blood pressures well controlled. 26% Only 25% of people with depression receive treatment. 25% 50% of patients hospitalized with congestive heart failure (CHF) are readmitted within 90 days. 50%

So What is Wrong? Not What We Do, But How We Do It Our Process of Care is Ineffective and Obsolete

Why? The Brief Visit Model is an Acute Care Model We Now Do Preventive Care, Chronic Illness Management, a Biopsychosocial and Family Systems Orientation

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 an annual retinal exam Percent with one of more glycohemoglobin tests Percent with one of more glycohemoglobin tests Percent of those having glycohemoglobin tests showing a level of <8.5 percent (goal <7.0) 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 an annual screening test for microalbuminuria Percent with two or more blood pressure checks per year 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 of those with one or more blood pressure checks having a systolic BP <135 (goal <<130/80) Percent with an annual lipid panel Percent with an annual lipid panel Percent of those with an annual lipid panel showing an LDL level <130 mg/dL (goal << 100) 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 Flu vax Pneumovax Pneumovax Dental visit Dental visit Cardiac screening test? Cardiac screening test? Lab monitoring for side effects of meds Lab monitoring for side effects of meds Annual foot exam Annual foot exam Baseline EKG? Baseline EKG?

Case con’t Cancer Screening needs: Colon- needs colonoscopy (or 3 other types of screening) Colon- needs colonoscopy (or 3 other types of screening) Cervical- needs pap if last <1-3 years prior Cervical- needs pap if last <1-3 years prior Breast- needs annual mammogram Breast- needs annual mammogram Osteoporosis screening and prevention Depression Screening and Management

Case con’t General health issues: General health issues: Adult Td Adult Td Weight management Weight management Advance Directives/DPOA Advance Directives/DPOA Culturally-sensitive care Culturally-sensitive care Patient Education Patient Education Self Management Self Management Tobacco Screen Tobacco Screen Alcohol screen Alcohol screen Domestic violence screen Domestic violence screen

The Ticking Clock in the Doctor’s Office “Patients on routine visits to their primary doctors often have lots of questions but not enough time to get good answers.” - New York Times, February 6, 2007

Hamster Care

The Time Problem Time Needed for Chronic Illness Care Time Needed for Chronic Illness Care Time Needed for Preventive Care Time Needed for Preventive Care Time Needed for Acute Care Time Needed for Acute Care Total face to face time for 2500 patients Total face to face time for 2500 patients Ann Fam Med 2005;3:209 Am J Pub Health 2003;93: hours a day for 2500 patients 7.4 hours a day 4.6 hours a day 22.6 hours/day

The Brief Visit Busy Office Schedule Model of Ambulatory Care Must Be Replaced By a New Process

Care Does Not Equal Visits Care Does Not Equal Visits Optimal care is based on deep, trustful relationships between practice and patients Optimal care is based on deep, trustful relationships between practice and patients Great relationship demands that we go far beyond visits in delivering care to patients Great relationship demands that we go far beyond visits in delivering care to patients An outmoded way of managing patients

The medical office is a bottleneck of episodic care that does a poor job of managing chronic illness and providing preventive services

Office Practice – Core Functions We Manage Relationships We Manage Relationships We Manage Knowledge We Manage Knowledge We Manage Resources We Manage Resources We Provide Skills We Provide Skills

Quality Ambulatory Care For The 21 ST Century Freedom From Error Freedom From Error Consistent Best Practice Consistent Best Practice Great Service Great Service

Common Mistakes in Office Practice Prescribing Prescribing Missed Diagnoses Missed Diagnoses Missed Lab/X-ray data Missed Lab/X-ray data Wrong Treatment Wrong Treatment Procedures Procedures

Content Overwelms No Time to Read it All

Information Overload

Future Office Practice Management of a Population of Patients Management of a Population of Patients Patient-Centered Care Patient-Centered Care Personal Medical Home Personal Medical Home Best Knowledge at the Point of Care Best Knowledge at the Point of Care Continuous Access to Multimodal Communication Continuous Access to Multimodal Communication

Future Office Practice A New Platform of Care A New Platform of Care Fewer Time Intensive Visits Fewer Time Intensive Visits Group Visits Group Visits Teamwork and Interpersonal Skills Teamwork and Interpersonal Skills Financial Practice Management Financial Practice Management

Information Technology Changing Medicine Patient Information EHR, All Clinical Data Communication Digital Connection of Patients with Caregivers Knowledge Management and Decision Support Tools

EHR Functions Patient Registry – needed for quality reporting and P4P Patient Registry – needed for quality reporting and P4P eRx – needed for avoiding medication errors eRx – needed for avoiding medication errors EHR – needed for organizing and accessing patient data EHR – needed for organizing and accessing patient data Clinical Decision Support – needed for smart practice and avoiding medical errors Clinical Decision Support – needed for smart practice and avoiding medical errors Patient Portal – needed for continuous access for communication and care Patient Portal – needed for continuous access for communication and care

The Complexity Of Modern Medicine Exceeds The Inherent Limitations Of An Unaided Human Mind David Eddy, M.D.

The New Communication Platform Interactive Web Site Interactive Web Site Electronic Communication For: Electronic Communication For: Lab Results And Other Data Lab Results And Other Data Chronic Illness Care Chronic Illness Care Behavioral Coaching Behavioral Coaching Minor Acute Problems Minor Acute Problems Online Family Meetings Online Family Meetings

Increased Chronic Care Needs About 150 million people (50% of population) have one or more chronic conditions About 150 million people (50% of population) have one or more chronic conditions Chronic conditions account for more than 75% of health care expenditures Chronic conditions account for more than 75% of health care expenditures 80/20 Rule: Limited number of conditions account for most of these health care expenditures 80/20 Rule: Limited number of conditions account for most of these health care expenditures

Improved Outcomes Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Resources and Policies Community Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Health Care Organization Chronic Care Model

Planned Care for Everyone Care is based on evidence Care is based on evidence Decision support is built into the work flow Decision support is built into the work flow Nothing drops through the cracks Nothing drops through the cracks Patient and Disease Registries Patient and Disease Registries Individual and Population based care Individual and Population based care Patient and care team are on the same page Patient and care team are on the same page Patients are activated to better manage their conditions Patients are activated to better manage their conditions Stepped-up care/resources tied to patient need Stepped-up care/resources tied to patient need

NCQA Recognition as a PCMH Access and Communication Access and Communication Patient Tracking and Registry Functions Patient Tracking and Registry Functions Care Management Care Management Patient Self-Management Support Patient Self-Management Support Electronic Prescribing Electronic Prescribing Test and Referral Tracking Test and Referral Tracking Performance Reporting and Improvement Performance Reporting and Improvement Advanced Electronic Communications Advanced Electronic Communications

A New Vision of Clinical Practice Responsibility for a Population of Patients Responsibility for a Population of Patients Manage Needs and Demands on a New Platform of Services (Web Based) Manage Needs and Demands on a New Platform of Services (Web Based) Prioritize Conditions and use a Team Approach Prioritize Conditions and use a Team Approach Take the Time to be Effective (Time to Heal) Take the Time to be Effective (Time to Heal) Change the Concept and Application of Productivity Change the Concept and Application of Productivity

“The more you can move demand away from office visits, the more time you’ll have to deal with patients who really need personal interaction.” --Donald Berwick, M.D.

DAILY SCHEDULE 2008 Thursday January 30, 2003 Daily Schedule Dr.. Wellbetter

Old Schedule First patient at 8 am and 12 patients each half day session First patient at 8 am and 12 patients each half day session 24 patient visits 24 patient visits 12 patient phone calls 12 patient phone calls Done at 6:30 PM Done at 6:30 PM Patients served Patients served -- 36

New Schedule Begin at 8 am and communicate with patients. Begin at 8 am and communicate with patients. First patient at 9:30. 6 patients/session First patient at 9:30. 6 patients/session 12 Patient Visits – vary in length from brief to extended 12 Patient Visits – vary in length from brief to extended 4 patient phone calls 4 patient phone calls 34 patient s in 2 sessions lasting min. each 34 patient s in 2 sessions lasting min. each Done at 5:30 PM Done at 5:30 PM Patients served Patients served -- 50

A New Model of Office Practice 50% more caring interactions each day 50% more caring interactions each day unhurried office visits each day unhurried office visits each day Advanced access – do today’s work today Advanced access – do today’s work today Patients get all the time they need Patients get all the time they need Patients receive the latest treatments Patients receive the latest treatments

How? An interactive practice website is a new platform of communication An interactive practice website is a new platform of communication 40-60% of patient needs handled online 40-60% of patient needs handled online Electronic medical record with imbedded knowledge management tools Electronic medical record with imbedded knowledge management tools Great service Great service

Financial Models for the New Model Shift of telephone to (time saver, $ neutral) Shift of telephone to (time saver, $ neutral) Reduce unnecessary visits (more $ in high demand office, less $ in lower demand) Reduce unnecessary visits (more $ in high demand office, less $ in lower demand) Payment for virtual care (Web Visit Charges) Payment for virtual care (Web Visit Charges) Prepaid service fee, monthly ($30) or annual ($360) Prepaid service fee, monthly ($30) or annual ($360) Prepaid Contracts Prepaid Contracts Pay for Performance incentives Pay for Performance incentives Billing for Group Visits Billing for Group Visits

The Holy Grail of Redesign Cost Reduction Cost Reduction Quality Improvement Quality Improvement Service Improvement Service Improvement

The Secret Sauce for Successful Redesign Care becomes continuous access rather than episodic Care becomes continuous access rather than episodic Care becomes proactive rather than reactive Care becomes proactive rather than reactive Patients become activated for self- management Patients become activated for self- management

Finances Follow Innovation The New Model is More Efficient Better Faster Cheaper!

Ideal Medical Practices Pioneered by Gordon Moore as Idealized Micropractice (IMP) Pioneered by Gordon Moore as Idealized Micropractice (IMP) Growing very fast in Family Medicine Growing very fast in Family Medicine Convocation at AAFP Convocation at AAFP Liberation and Great Enthusiasm Liberation and Great Enthusiasm Personalized Medical Practices Personalized Medical Practices Concierge Care for Everyone Concierge Care for Everyone

Greenfield Health 9 FPs and IMs Practice in Portland, OR, 2 offices 9 FPs and IMs Practice in Portland, OR, 2 offices Chuck Kilo as Leader (IHI Experience) Chuck Kilo as Leader (IHI Experience) Interactive Website, Web Messaging, Telephone and Selective Use of Office Visits Interactive Website, Web Messaging, Telephone and Selective Use of Office Visits Physician Spends Half Day Seeing Patients – Visits 30 Minutes or Longer Physician Spends Half Day Seeing Patients – Visits 30 Minutes or Longer Half Day Messaging Half Day Messaging Volume is 20% Visits, 40% Telephone, 40% Web Messaging Volume is 20% Visits, 40% Telephone, 40% Web Messaging Annual fees range from $195 to $495 depending on age Annual fees range from $195 to $495 depending on age

Kaiser Permanente HealthConnect 24 Hour Access to Accurate and Comprehensive Health Care Information and Services

Health Partners Online User Growth 37,776 MyChart active users

Birth Announcement: Google, Microsoft, & Dossia Create the Personal Health Information Network Birth Announcement: Google, Microsoft, & Dossia Create the Personal Health Information Network Healthcare Informatics April 17, 2008

Relationship Centered Care What is the 21 st Century Application?

Substance is enduring, form is ephemeral. Failure to distinguish clearly between the two is ruinous. Success follows those adept at preserving the substance of the past by clothing it in the forms of the future. Preserve substance; modify form; know the difference. Wise Words from Dee Hock

Whenever you see a successful business, someone once made a courageous decision Peter Drucker

Change Is Disturbing When It Is Done To Us. Change Is Exhilarating When It Is Done By Us Rosabeth Kantor Harvard Business School

Human Nature Changes Little Caring Remains Primary What Changes Are The Tools And Methods We Use