Creating an ideal practice L. Gordon Moore AAFP/STFM November 2006

Objectives Explain the components of an ideal practice Understand how innovation approaches in the internet helps practices and patients with chronic conditions Describe outcomes achieved by some ideal practices

Primary Care Score: 2 = Stronger From Barbara Starfield, MD UK SP US Primary Care Score: 2 = Stronger From Barbara Starfield, MD

Barriers to primary care Conclusions: The disproportionate ED utilization for chronic ACS conditions by black persons and Medicaid patients does not appear to be explained by either differences in disease prevalence or disease severity. Follow-up arrangements for black persons, Medicaid, and uninsured patients suggest that they are less likely to have ongoing primary care. Barriers to primary care appear to contribute to the higher ED and hospital utilization rates seen in these groups. Oster, Ady MD; Bindman, Andrew B. MD Medical Care Volume 41(2), February 2003, pp 198-207

Cost of inadequate primary care Abstract: The quality of care received by Medicare beneficiaries varies across areas. We find that states with higher Medicare spending have lower-quality care. This negative relationship may be driven by the use of intensive, costly care that crowds out the use of more effective care. One mechanism for this trade-off may be the mix of the provider workforce: States with more general practitioners use more effective care and have lower spending, while those with more specialists have higher costs and lower quality. Improving the quality of beneficiaries' care could be accomplished with more effective use of existing dollars. Baicker K. Chandra A. Health Affairs. Suppl Web Exclusive:W184-97, 2004.

If you get it, is it good enough? RESULTS: Participants (a random sample of adults living in 12 metropolitan areas in the United States) received 54.9 percent of recommended care. CONCLUSIONS: The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. New England Journal of Medicine, June 26, 2003.

What makes care “good”? Having trust in cancer information from the doctor or other health care professional was most predictive of being up to date. Other predictive factors include having a desire for cancer information from personalized reading materials and using the Internet from home. Ling BS. Klein WM. Dang Q. Journal of Health Communication. 11 Suppl 1:181-90, 2006.

Patient perspective of “why we don’t show up” Delay for appointment: “I can’t get in when I want/need to get in” Respect: “You make me wait in your office” “You don’t take the time to listen to me” Transportation and child care were logistical barriers, but respondents noted they could be overcome. Lacy, Paulman, Reuter, Lovejoy. Ann Fam Med 2004; 2: 541-545.

The paradigm shift adapted from Bodenheimer et al, JAMA, 2002 Traditional Model Collaborative, patient centered care Diagnosis Treatment Roles in care: Physician is the expert and caregiver- creates the treatment plan. Mechanism of change Patient compliance (external motivation) Response to gaps in adherence/outcomes: Poor patient compliance Style emphasis: Objective detachment Discovery Dialogue Shared expertise; patient as caregiver Co-creation of plan Mechanism of change: Building understanding and confidence Treated as opportunities for learning, problem solving and redesign of plans Style emphasis: engaging, warm, curious, supportive, hopeful

Concerns, Socioeconomics, Obstacles to Self-Care For Most Health Problems the TOP Is Attained Only When The Patient is a Collaborating Partner I Receive Exactly The Care I Want And Need Exactly When And How I Want And Need It Result Practice Redesign Patient Portals Registry Access, Reliability Care Planning Patient Activation and Support Shared Decision-Making Action Problem-Solving Timely-Feedback of Actionable Information Summary of Tailored Information Function, Symptoms, Burden Of Illness, Concerns, Socioeconomics, Obstacles to Self-Care Prevention Chronic Disease Patient Experience Measures Clinician, Health System What is the Matter? Patient, Community What Matters Patient/Clinician Divide

Closing the gap Wasson, Johnson, et al. JACM Vol. 29, No. 3, pp. 199–206

Key practice components Moore LG, Wasson JH, JACM Vol 29, No 3, pp. 195-198

In Case a “Multi-Factorial,” Left and Right Pyramid Perspective is Not Complicated Enough We have Diseases! Some physician office practices are implementing strategies to improve measured performance for the care of many diseases. However, a disease-by-disease focus is inherently inefficient.

Fortunately, Most Patients Fit Categories for Generic Planned Care

Components of Generic Planned Care Practices find out what matters to patients - (patient-centered care); Practices help patients become more confident self-managers by using generic problem-solving approaches common to most health problems - (collaborative care); and Practices make changes in their function so that this patient-centered, collaborative care is delivered efficiently, reliably, and effectively.

Taking Action on the What We Know About PCCC and How to Attain It Screen all Design across-the-board solutions Open access scheduling High continuity Efficient processes for patient and information flow Access to very good information Stepped self-management support based on patient need

Motivated Traditional Practices IMPs Compared to Other Practices (for similar patients with common chronic problems) IMPs (n=450) Motivated Traditional Practices (n=1200) National Sample (N=25,000) On Same Page Doctor or Nurse Aware of Feelings 87% 72% 51% Information Exchange Excellent or Very Good Information 83% 68% Care Processes Very Easy Access 64% 46% 52% Nothing Needs Improvement 55% 42% 40% Overall Patient-Centered “I receive exactly the care… 60% 25%

Where we’re going www.IdealMicroPractice.org www.IdealMissouriPractice.org Incubators Pilots for new training, finances I’ll post the presentation to my web site: www.IdealHealthNetwork.com