Transforming Residency Practices into Medical Homes Perry Dickinson, MD Department of Family Medicine University of Colorado School of Medicine

Outline What is the Patient Centered Medical Home? Colorado FM Residency PCMH Project Lessons learned Questions and (hopefully) answers

What is the Patient Centered Medical Home? The PCMH is an approach to providing enhanced, comprehensive primary care for children, youth, and adults. Has gained a great deal of traction as a platform for improving care and decreasing costs Builds on core family medicine principles, but with some key changes

Why Do We Need to Change? – Health Care System Perspective Spending incredibly too much for health care Increasing recognition that current system unsustainable Mediocre quality in multiple areas Increasing recognition of the potential role of primary care to increase quality and decrease costs There is compelling, widely available evidence coming from academic centers, think tanks, plans, and government studies that find unexplainable disparities in healthcare quality, cost, and outcome. I’m sure you’re all familiar with the problems: IOM Quality Chasm - Difference between what healthcare should be and what it is now is not a gap, it’s a chasm…. Mediocre quality – Rand Study - with the current - giving 55% of recommended care - Nation / World news: Mediocre doctoring the norm: Study: Proper care given just 55 percent of the time – June 2003 and March 2006 – NOW HIT THE LAY PUBLIC AND BUSINESS JOURNALS NEW STUDY PROVIDES ROAD MAP TO PREVENTIVE SERVICES WITH GREATEST HEALTH IMPACT, BEST COST VALUE - More than Half of Americans Who Need Valuable Preventive Services Continue to Go Without Them (by Partnership for Prevention - Sponsored by the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ)) - Sheds light on the startling fact that more than 50 percent of Americans who need these valuable preventive services continue to go without them. The three most valuable preventive health services that can be offered in medical practice today, each of which save more money than they cost and provide enormous health benefits are: Discussing daily aspirin use with at-risk adults to prevent cardiovascular disease Immunizing children Intervening with smokers to help them quit Developed a ranking of 25 recommended services based on those that provide the greatest health benefits, both in terms of saving lives and improving quality of life, while offering the most value for the health care dollars According to the study, five of the highest ranking services are being utilized by less than half of the people who need them. These are: 1.) discussing daily aspirin use with at-risk adults; 2.) screening adults age 50+ for colorectal cancer; 3.) intervening with smokers to help them quit; 4.) vaccinating older adults against bacterial pneumonia; and 5.) screening young, sexually active women for Chlamydia. Killing 44K - 98K people every year from medical errors It’s not bad doctors – we need to move from a blame and shame culture – but as physicians, we can no longer accept the status quo. There is compelling, widely available evidence coming from academic centers, think tanks, plans, and government studies that find unexplainable disparities in healthcare quality, cost, and outcome. Even after disputes regarding methodology, severity adjustments and peer reviewed critiques rinse the data and findings, the evidence demonstrates that value of the health care purchased is hardly uniform. (for the money being spent on healthcare, the quality needs to be improved). Part of the issue is we are taught to take care of each patient individually – but when you look at the POPULATION of patients as a whole, the numbers look very mediocre We certainly want to keep the good relationships with our patients – but we also need NEW and Better Systems to get this job done.

Cost per capita vs healthy life years Best Organization for Economic Cooperation and Development data, 2000

International Quality Comparison

Need for Change – Primary Care Perspective Primary care clinicians – on a treadmill Reimbursement system slanted against primary care, toward procedures, specialists, hospitals Very tight financial margin Have to see more and more patients to survive Can’t deliver the type of care we want and need to do

What’s Different with PCMH? Builds on strengthening the pillars of primary care (continuity, comprehensive care, coordination of care, initial access to care) Adds different approaches to organizing care based on the Chronic Care Model Adds use of Information Technology tools Expanded importance of teamwork – among clinicians, staff, patients, families, specialists, hospital, community

Core Features of the PCMH Centered around continuity relationship with a personal physician – but team-based care Integrated mental, behavioral health Patient’s care coordinated by the practice Patient-centered; self-management support Ongoing quality improvement Population-based care Enhanced access Payment reform

Payment System Several models proposed Most prevalent – blended payment model: Traditional fee for service, plus… Per member per month care management fee based on level of services provided, plus… Pay for performance Multiple pilots underway, including Colorado

Day in the life of Primary Care Mid afternoon. Running behind. Has already seen 22 patients. 55 y/o man with dizziness, rash and chronic rhinorrhea Has DM, requesting refills. Last seen 9 mos ago No labs for over a year – not well-controlled then Info scattered through chart, hard to find Last retinal exam unclear – no record You evaluate the acute symptoms, order labs, refill meds. No time for diabetic education. Ask to return in a month, but will he return then?

Day in the Life of a PCMH The MA checks the next day’s schedule at 4 PM and identifies chronic care patients. Same patient - 55 y/o with uncontrolled diabetes Recently was seen for dizziness and now returning for a planned care visit She notes that he needs a Pneumovax, lipid test, & retinal exam and prints his flow sheet. Patient goes straight to exam room, MA checks the patient in, checks BP & foot exam, screens for depression, makes referral for eye exam, orders lipids and Hgb A1c, gives Pneumovax All done before seeing the physician. A transformed practice requires additional time for MA, advanced training of MA and Standing Orders.

Day in the Life of a PCMH Physician performs assessment, begins self-management discussion, adjusts meds, and plans next visit. Patient sent to nurse care manager who helps patient to develop personal care plan, sets up for a diabetes education group in the community MA calls patient in 2 weeks to see if he has questions or problems, makes sure no problems with med change, reconfirms next visit. Reality? This comes from one of our PCMH Demonstration Project practices Physician has time to activate patient because of bidirectional information and delegates duties.

The Colorado Family Medicine Residency PCMH Project 3-year grant from the Colorado Health Foundation; began in December 2008 Goal: To transform the 10 Colorado FM Residency Programs into medical homes through practice improvement and curriculum redesign

What is Involved? Initial Engagement Engagement of leadership, residents, staff Start working on forming improvement teams Assistance with initial IT issues Practice/program discussions of PCMH to help form the vision Sponsoring organizations – look for support, try to remove barriers

Improvement Teams Practice improvement is a team sport Have to make time and space for reflection on areas needing change, planning Best way of doing this - practice “Improvement Team” with regular meetings to consider and plan improvement efforts Should include people from all major parts of the practice – diversity, teamwork is crucial Takes time and persistence for team to become optimally functional

Practice Coaching Assessment of current status in practice Feedback assessment to practice Help form improvement teams Initially facilitate improvement team process but transition to practice taking over Serve as connection to resources, best practices Goal is to establish a sustainable change & improvement process in the practice

Curriculum Redesign Facilitation and consultation for PCMH-related curriculum changes Changes to free up residents to participate in PCMH and QI efforts Shared resource development across programs (lectures, modules, etc) Active involvement of residents in practice redesign process PCMH practices for residents to experience

Collaboratives Meetings of representatives of all practices and programs Planning, sharing, educational – highly interactive Two collaboratives per year First one May 2009 – 105 people from the residency programs and practices Second - October 2009 – 135 from programs Third – May, 2010 – 160 from programs

Practice Goals Achieve NCQA PPC-PCMH recognition Improve level of medical homeness: PCMH Clinician Assessment Practice Staff Questionnaire (practice culture) Practice PCMH Monitor (recently developed) Improve quality measures in two clinically important areas chosen by the practice

Curricular Goals Revision of curricula to allow resident participation in PCMH and QI efforts Improved resident achievement of PCMH competencies Improved resident use of PCMH elements as measured by PCMH Clinician Assessment Implementation of PCMH curricular elements

Challenges for Residency Practices Inconsistent resident availability Lots of part-time faculty and resident providers Large practices – most have 40-90 employees Goals and beauracracy of sponsoring hospitals Staff often controlled by hospital Hierarchical management structures Rigid and extensive residency curricular and structural requirements

Lessons Learned – Practice Transformation Becoming a medical home takes time, requires fundamental change in multiple areas Change is difficult, and this is a lot of change Have to have a robust change management and quality improvement process Outside support (from a practice coach) can really help – but practice needs to be open to having a coach

Lessons – Structure of Support No established road map to the medical home NCQA PCMH standards provide some framework – but incomplete, insufficient Some things need to be done early to enable later changes (vision, team formation, staff engagement, registry implementation) Moving toward more structured approach, but have to balance with practice choice Lack of payment reforms limit changes in some areas, but not others

Lessons - Curriculum Residents are more energized and ready to change than faculty Difficult but crucial to involve residents on a regular basis in the change process Developed PCMH competencies – will evolve Curriculum issues may change over time Initial need for didactics & projects in key PCMH areas Gradual shift to more experiential learning

Lessons - Sustaining Change Identified a need to more formally train internal QI Team Leaders to create sustainability Mix of didactic, discussion, experiential with support by our project team Varies according to audience (staff, physicians) Creating a Learning Community Learning Collaboratives working well to promote sharing Project staff creating connections between programs working on similar areas

PCMH – Huge Cultural Issues Three key areas for practice cultural change: Leadership Change process requires a shift toward less hierarchical management Team-based care and improvement process Clinicians and staff not used to working in teams Patient-centeredness Traditional care practice and physician centered; requires a shift for everyone

PCMH is a Team Sport No way for primary care clinicians to do everything their patients need themselves Multiple studies showing that delegating responsibilities to the staff has very positive results – patient, staff, clinician satisfaction, quality and efficiency of care Goal is everyone working at the top of their license and skills We physicians have difficulty delegating Staff not trained for some of these tasks

Effective Leaders for Change Provide an initial vision – but engage everyone in further developing the vision Refer to the vision regularly to focus work Help everyone figure out how they can contribute to the vision Make time for reflective, interactive team meetings Encourage an open exchange of ideas Value and nurture diversity of people, ideas, and experiences

Effective Leaders Empower people to work at highest level Hold people (and self) accountable Help show a way forward when things are stuck Are not afraid of failure Share information freely Create a true shared leadership model Often work through others to achieve goals Give recognition and awards

Reality Even if you are on the right track, you’ll get run over if you just sit there ~ Will Rogers We do not have a lot of time. Other agents will fill the void.

Thank You! Contact Information: Perry Dickinson: perry.dickinson@ucdenver.edu