Transforming Primary Care: What Works and What’s Next A chartbook created by the staff of Improving Chronic Illness Care At the MacColl Institute for Healthcare Innovation Group Health Research Institute Supported by The Robert Wood Johnson Foundation Grant # 053022

I. Primary care in crisis 2

Changing demography and practice content Substantial proportion of ambulatory visits among adults are for chronic illness management1 Chronic problem— routine Chronic problem— flare-up All patients 30% 9% Age 25-44 26% Age 45-64 37% 10% Age 65+ 42% 11% 1 “National Ambulatory Medical Care Survey.” Advance Data, No., 387, 2007. Accessed December 13, 2009, from http://www.cdc.gov/nchs/data/ad/ad387.pdf. Note: See slide notes for citations in this chartbook or the CD’s Articles & Websites section. 3

Greater care complexity Studies2,3 estimate that it would take 7.4 hours to deliver all recommended preventive services and 10.6 hours per working day to deliver all evidence-based care for chronic conditions to a primary care panel. “These excessive demands contribute to long waiting times and inadequate quality of care for patients.”4 Concern about one’s ability to manage complex, chronically ill patients may contribute to driving career choice away from primary care. 2 Primary Care: Is There Enough Time for Prevention? Kimberly S. H. Yarnall, Kathryn I. Pollak, Truls Østbye, Katrina M. Krause, and J. Lloyd MichenerAm J Public Health. 2003 April; 93(4): 635–641. Pubmed Identification (PMID): PMC1447803 3 Is there time for management of patients with chronic diseases in primary care? Østbye, T., Yarnall K.S., Krause, K.M., Pollak, K.I., Gradison, M., Michener JL. Ann Fam Med. 2005 May-June; 3(3):209-14. PMID: 15928223 4 Primary care—will it survive? Bodenheimer, T. N Engl J Med. 2006 Aug. 31; 355(9):861-4. PMID: 16943396 4

Quality of current primary care Patients with major chronic illnesses receive recommended care about half of the time.5 Half of patients leave the doctor’s office without understanding what their physician said.6,7 These deficits are now perceived by patients, physicians and policymakers.8 Public Physicians Policymakers People with chronic conditions usually receive adequate medical care 48% 45% 22% 5 The quality of health care delivered to adults in the United States. McGlynn, E.A., Asch, S.M., Adams, J., et al. N Engl J Med. 2003 June 26; 348:2635-45. PMID: 12826639 6 Studies of doctor-patient interaction. Roter, D.L., Hall, J.A. Annu Rev Public Health. 1989;10:163-180. PMID: 2655629 7 Closing the loop: physician communication with diabetic patients who have low health literacy. Schillinger, D., Piette, J., Grumbach, K., et al. Arch Intern Med. 2003 Jan. 13.; 163(1):83-90. PMID: 12523921 8 Physician, Public and Policy-Maker Perspectives on Chronic Disease Conditions. Anderson, G.F. Archives of Internal Medicine. Feb. 24, 2003: 163(4); 437-42. PMID: 12588202 5

The physician workforce in decline The proportion of Internal Medicine residents becoming generalists declined from 55% to 2% within a decade.9 Income, debt and work hours are all cited as factors. 9Factors associated with medical students' career choices regarding internal medicine. Hauer, K.E., Durning, S.J., Kernan W.N., Fagan, M.J., Mintz, M., O'Sullivan, P.S., Battistone, M., DeFer, T., Elnicki, M., Harrell, H., Reddy, S., Boscardin, C.K., Schwartz, M.D. JAMA. 2008 Sept. 10; 300(10):1154-64. PMID: 18780844 6

A need for major healthcare reform Do primary care physicians (PCPs) in the U.S. and elsewhere see the need for major healthcare reform?10 Percent saying AUS CAN FR GER ITA NET NZ NOR SWE UK US Only minor changes are needed 23 33 41 18 38 60 42 56 37 47 17 Fundamental changes are needed 71 62 53 51 58 57 40 54 50 67 System needs to be completely rebuilt 6 4 31 1 2 7 3 15 10 A survey of primary care physicians in eleven countries, 2009: Perspectives on care, costs, and experiences. Schoen, C., Osborn, R., Doty, M.M., Squires, D., Peugh, J., Applebaum, S. Health Aff (Millwood). 2009 Nov.-Dec.; 28(6): w1171-83. Epub, 2009 Nov. 2. PMID: 19884491 7

Primary care’s decline: Does it matter? The vast majority of the population prefers a PCP, while 95% of Americans want one practice and/or clinic where doctors and nurses know you, provide and coordinate the care that you need.11 Countries with better primary care have better health outcomes.12 U.S. states with higher primary care/population ratios have reduced costs and better quality healthcare.13 11 Toward higher-performance health systems: adults' health care experiences in seven countries, 2007. Schoen, C., Osborn, R., Doty, M.M., Bishop, M., Peugh, J., Murukutla. N. Health Aff (Millwood). 2007 Nov-Dec; 26(6):w717-34. PMID: 17978360 12 Contribution of primary care to health systems and health. Starfield, B., Shi, L., Macinko, J. Milbank Q. 2005; 83:457-502. PMID: 16202000 13 Quantifying the health benefits of primary care physician supply in the United States. Macinko, J., Starfield, B., Shi, L. Int J Health Serv. 2007; 37(1):111-26. PMID: 17436988 8

And how will we pay for healthcare? The U.S. is currently spending 17% of GDP, the most of any nation.14 If healthcare spending grows at the current rate, a staggering 119% of the real increase in income over the next eight decades will be consumed by healthcare spending, leaving nothing for other needs. 14 Increased spending on health care: Long-term implications for the nation. Chernew, M.E., Hirth, R.A., Cutler, D.M. Health Aff (Millwood). 2009 Sept.-Oct.; 28(5):1253- 5. PMID: 19738238 9

What can we do? The future of primary care (and our healthcare system) depends upon its ability to improve the quality and efficiency of its care for the chronically ill. It will also require a recommitment of primary care to meet the needs of patients for timely, patient-centered, continuous and coordinated care. That will require a major transformation or redesign of practice, not just better reimbursement. However, such transformations will be difficult to motivate or sustain without payment reform. 10

II. What works 11

What works – Previous disks in this series Volume 1: “Tackling the Chronic Care Crisis” explained the Chronic Care Model (CCM) and summarized the evidence base that has developed in the last decade. Visit our website at: http://www.improvingchroniccare.org/index.php?p=Tackling_the_Chronic_Care_Cris is_CD-Rom&s=172 12

What works – Previous disks in this series Leadership Volume 2: “It Takes A Region” examined the developing evidence base for regional healthcare improvement and proposed a framework to guide community improvement efforts. Visit our website at: http://www.improvingchroniccare.org/index.php?p=It_Takes_A_Region_CD- Rom&s=238 13

What works: Other tools developed by ICIC Visit our website, www.improvingchroniccare.org to learn more about the following tools:* We have a practice toolkit, available to download from our website, that is a summary of our lessons learned and a repository of useful tools. We also have a toolkit to provide busy clinical practices with a set of tested resources and tools to share with patients and families in the day-to-day management of chronic conditions. You can access the tools on our website using the following links: “Integrating Chronic Care and Business Strategies in the Safety Net: A toolkit for Primary Care Practices and Clinics” can be found at: http://www.improvingchroniccare.org/index.php?p=Toolkit&s=244 "Partnering in Self-Management Support: A Toolkit for Clinicians” can be found at: http://www.improvingchroniccare.org/index.php?p=Self- Management_Support&s=39 14 * See the slide notes page for specific URLs.

What qualities do practices with improved outcomes share? Success factors What qualities do practices with improved outcomes share? Team care – Clinical tasks shared with non-physician staff 2. Information technology – Functions that support healthcare planning and proactive, population based care 3. Planned care – Patient needs identified prior to encounters and systematically addressed 4. Self-management support – Engaging patients as partners in care 15

Successful care depends on everyone on the team For example: Depression Management Medical assistant administers PHQ-9 MD diagnoses depression and initiates treatment Population manager enters patient and data in registry Care manager follows the patient over time provides self-management support Consulting psychiatrist provides advice and care manager and MD 16

Create a successful team Plan and improve care together. Define roles and tasks and distribute them among team members. Train people for their roles. 17

Incorporate improvement into daily work Meet briefly and often to review performance and plan PDSA cycles. Make improvement a part of the clinical team’s day-to-day thinking and work. Communicate regularly with senior leaders to discuss successes and barriers. 18

Successful teams use a registry For example: Most of the Medicare plans providing the best diabetes care use a registry.15 Characteristic High-performing plans Low-performing plans P HbA1c >9.5 20% 49% Use of a registry 78% 40% .02 15 The relationship between organizational systems and clinical quality in diabetes care. Fleming, B., Silver, A., Ocepek-Welikson, K., Keller, D. Am J Manag Care. 2004 Dec.; 10(12):934-44. PMID: 15617369 19

Why is registry functionality so critical? Population management Allows practices to monitor entire practice panel and reach out to those needing service. Encounter planning and reminders Easy access to data on guideline adherence and key indicators facilitates productive interactions. Performance measurement 20

Successful teams support self-management Organize and train team members to provide basic self-management support. Identify and use effective self-management support resources in their area. Make self-management support a part of every interaction. 21

Self-management support must include key community resources Encourage patients to participate in effective community programs that provide important services (e.g. exercise, self-management support, smoking cessation, peer support, etc.). Form partnerships with key community organizations to support or develop programs. 22

What works Organizational and environmental factors associated with high-quality care Leadership — Leader attitudes about and level of support for QI a strong predictor of success. Financing — Providing financial incentives for transforming practice predicts involvement in QI and perhaps success. Effective practice management systems — Must be in place for practices to transform their clinical systems. 23

What works Organizational and environmental factors associated with high-quality care Trusted performance measurement is a powerful motivator for practice involvement in QI. Networking smaller practices can provide leadership, motivation and support for otherwise isolated practices to engage in QI. 24

What works: Formal learning structures like breakthrough series collaboratives Over the last decade we have worked directly or indirectly with over 1,500 practices in collaboratives Teams that use PDSA cycles based on the CCM systematically over time:16 Usually see process improvement May or may not see outcome improvement Enjoy their work more 16Evidence on the Chronic Care Model in the new millennium. Coleman, K., Austin, B.T., Brach C, Wagner, E.H. Health Aff (Millwood). 2009 Jan.-Feb.; 28(1):75-85. PMID: 19124857 25

Limitations of breakthrough series collaboratives Collaboratives have demonstrated positive change, but there are limits: Small percentage of eligible practices participate — usually early adopters Reach within a practice organization limited to the most motivated Changes often made in ways that are not sustainable Can encourage project-based (i.e. time-limited) thinking 26

III. What’s next: The promise and challenge of the Patient-Centered Medical Home (PCMH) 27

The CCM and the PCMH: Complementary models Primary care is regarded as a linchpin to current healthcare reform efforts. The PCMH is being proposed as a way to rejuvenate primary care. The current PCMH model is a combination of the CCM and the Pediatric Medical Home model. 28

Understanding the origin of the Patient-Centered Medical Home The Pediatric Medical Home concept arose out of frustration with the fragmented care of children with special needs. Medical Home model puts the relationship with the PCP and team at the center of a patient’s care, and makes explicit the expectations of the PCP to provide timely, continuous, patient-centered and coordinated care. 29

Understanding the origin of the Patient-Centered Medical Home Both the PCMH and CCM rest on the clinical evidence of practice changes that lead to improvements in patient care and outcomes. Both models advocate that every healthcare experience (e.g. visit, referral, admission, etc.) connects the patient back to their PCP. Both emphasize and support the patient role in decision-making and care. 30

Key features of a Patient-Centered Medical Home17 Personal physician – First contact, continuous and comprehensive care Team care – Collectively take responsibility for ongoing care Whole person orientation – Take responsibility for all patient needs by delivering or arranging care Coordinated care – Across all elements of the healthcare system Quality and safety – By implementation of CCM, continuous QI and voluntary recognition process Enhanced access – Via open scheduling, expanded hours and new options for communication Payment – Recognizes value of the PCMH, pays for coordination and electronic communication with patients, and supports IT use 17Joint Principles of the Patient-Centered Medical Home — March 2007. The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association, published the Joint Principles in 2007. The statement can be accessed at: http://www.medicalhomeinfo.org/joint%20Statement.pdf 31

Is the Patient-Centered Medical Home based on evidence? The CCM holds considerable evidence of salutary effects on quality of care.16 Improved continuity is associated with better healthcare, patient satisfaction and outcomes.18 Access and coordination are valued by patients, and interventions directed at improving transitional care have improved care and outcomes.19 16 Evidence on the Chronic Care Model in the new millennium. Coleman, K., Austin, B.T., Brach, C., Wagner, E.H. Health Aff (Millwood). 2009 Jan.-Feb.; 28(1):75-85. PMID: 19124857 18 Continuity of care: a multidisciplinary review. Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. British Medical Journal. 2003; 327(7425):1219-21. PMID: 14630762 19 Coordinating Care – a perilous journey through the health care system. Bodenheimer, T. N Engl J Med. 2008 Mar. 6; 358(10):1064-71. PMID: 18322289 32

What are the goals of the PCMH? For long-term success and impact, PCMH practices must: 1. Improve outcomes for patients with major chronic illnesses. 2. Reduce costs through fewer emergency room visits and hospitalizations (especially re-admissions and admissions for ambulatory-sensitive conditions. 3. Improve both patient and provider experience. 33

Can these goals be achieved? The Group Health PCMH Pilot20 PCMH implemented in one primary care clinic with 10,000 patients Compared with two other clinics with similar baseline performance One year, in comparison with control clinics, the PCMH clinic experienced: Greater improvement in patient experience Dramatic reductions in provider burnout and dissatisfaction Small improvements in clinical quality across the board Significant reductions in avoidable hospitalizations and emergency room and urgent-care visits Improvements largely maintained in year two 20 Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Reid, R.J., Fishman, P.A., Yu, 0., Ross, T.R., Tufano, J.T., Soman, M.P., Larson, E.B. Am J Manag Care. 2009 Sept. 1; 15(9):e71-87 PMID: 19728768 34

What we are learning about implementing the PCMH21 Practice transformation requires “epic … redesign,” not just incremental changes. Even in practices with EMRs, achieving “meaningful use” often requires major educational and technologic intervention. Change fatigue is a serious concern. To make changes, practices need “adaptive reserve” — leadership, QI time and solid relationships to weather the storm. Transformation is local; intervention ideas must be molded to fit local environments. 21 Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Nutting, P.A., et al. Ann Fam Med. 2009 May-June; 7(3):254-60. PMID: 19433844 35

What we still need to learn about the elements of the PCMH model Practical approaches for making self-management support a routine component of all transactions with patients. How best to provide 24/7 access. Which coverage alternatives best meet patient needs and reduce ER and hospital use? How best to coordinate care and link to community resources. Which alternatives best meet patient and provider needs and reduce ER and hospital use? 36

What we still need to learn about implementation Is there a best QI method to support PCMH implementation? Is there a best strategy for supporting practices involved in PCMH implementation? What practice payment reforms best motivate engagement in transformation? What practice payment reforms lead to the most successful and sustainable implementation of the PCMH? How important is networking of smaller practices, and what network structures are most successful? How do we best measure PCMH implementation and effectiveness? 37

Transformation is a Developmental Process21 It begins with a solid core structure. Well-functioning clinical and QI teams Effective financial management Committed leadership Functional IT Develop or nurture the “adaptive reserve”. Try to change both the practice AND the environment in which the practice operates (e.g. the medical neighborhood). Have to address professional isolation and relationships between primary and hospital/specialty care Try to address financial barriers and incentives with payors 21 Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Nutting, P.A., et al. Ann Fam Med. 2009 May-June; 7(3):254-60. PMID: 19433844 38

The structural barriers to overcome becoming a medical home Difficulty defining the practice’s “panel” Lack of supportive information technology Lack of financial incentives Lack of hospital or specialist support of care coordination Practice isolation from partners and QI infrastructure 39

A real opportunity There is real possibility of healthcare reform that includes an emphasis on primary care renewal. There is strong support for a model (the PCMH) that can improve healthcare and reduce costs. There is growing evidence and experience base for transforming practice. 40

Thank you to The Robert Wood Johnson Foundation and to all of our partners in improving chronic care over the last decade. 41

Continue to find us at: www.improvingchroniccare.org 42