Frank deGruy September 12, 2011

 Our Healthcare System Is Broken  What Distinguishes A High-Quality System?  The Definition of Primary Care  Improving Healthcare Services  The Principles of Redesign  The Particulars of Redesign  Sustainability

“Never has a nation spent so much on so few for so little.” Larry Green

Answer : A foundation of high-quality primary care “Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, [no matter how measured]. The means by which primary care improves health have been identified….” Contributions of Primary Care to Health Systems and Health Starfield B, Shi L, Macinko J. The Milbank Quarterly; 83:

 Improved health  Equity in health care  Lower cost

“Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” Defining Primary Care: An Interim Report. Institute of Medicine Committee on the Future of Primary Care. National Academy Press, Washington DC, 1994

“…responsible for providing for all the patient’s health care needs…” “Care is coordinated and/or integrated across all elements…” Joint Principles of the Patient Centered Medical Home American Academy of Family Physicians (AAFP) American Academy of Pediatrics (AAP) American College of Physicians (ACP) American Osteopathic Association (AOA) February 2007

 Acute Care  Chronic Care  Preventive Services  Self-management  Education  Coordination & integration  Mental and Medical  Others

 Function, not location  Fragmentation  Financing

11 Number of physical symptoms

12 Robert Graham Center, “Why there must be room for mental health in the medical home; NBGH: An Employers’ Guide to Behavioral Health Services

13 McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270: Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, JAMA 2004;291:

Myopia Psoriasis Hypothyroidism Allergies Depression Multiple Sclerosis Epilepsy Chronic Back Pain Infertility Crohn’s Disease GERD Ulcerative Colitis Sickle Cell Disease Type I Diabetes Parkinson’s Cystic Fibrosis CAD Chronic Hep B Osteoporosis Cerebrovascular Dz Hypertension Hyperlipidemia Asthma CHF Schizophrenia Type II DM Alzheimer’s Obesity Bipolar Disorder Addictions Requirement for behavior change Motivation to change

 Vision for serving the whole person  PCMH as a prototype  CMHC’s already ahead in some areas  Care managers  Wraparound services  Chronic illness management  Behind in others  Medical illness and medical system  Pace of practice  Sharing health information

 Culture of change  QI  Plan-Do-Study-Act (PDSA)  Measurement-based outcomes  Team-based care  Leadership for change  New principles of communication  Self-management, groups, peer support  External partnerships

 Registries  Comprehensive personal care plan for all  Solid expertise on hand for  Common physical conditions  The deep end  Health behavior change  Self management  Preventive services

 Payment reform is an absolute prerequisite  Eliminate fragmentation of payment  Commingled funding streams  Accountability for all elements of health  Pay for health, not procedures, not visits  Pay for quality care  Pay for collaboration & coordination  Pay patients for healthy living  Pay for innovation  Reward cost savings