1. New Community, New Practice: Patient-Centeredness in a New Model Practice STFM/AAFP Conference on Practice Improvement S5: November 10, 2006 David B. Graham, MD University of Colorado Family Medicine Residency

2. S5: November 10, 2006New Community, New Practice David B. Graham, MD 2 Objectives Discuss elements of the New Model of practice that enhance patient- centeredness. Integrate concepts of Chronic Care Model (CCM) into clinical practice and education. Utilize available resources for practice redesign and transformation.

3. S5: November 10, 2006New Community, New Practice David B. Graham, MD 3 Rationale for Change The system is broken Dramatic increase in chronic conditions Institute of Medicine (IOM) report Future of Family Medicine (FFM) report Institute for Healthcare Improvement (IHI) principles

4. S5: November 10, 2006New Community, New Practice David B. Graham, MD 4 The “Health” of US healthcare “Between the health care we have and the health care we could have lies not just a gap, but a chasm.” “In its current form, habits, and environment, American health care is incapable of providing the public with the quality health care it expects and deserves.” IOM, “Crossing the Quality Chasm” (2001)

5. S5: November 10, 2006New Community, New Practice David B. Graham, MD 5 Institute of Medicine (IOM) Crossing the Quality Chasm, 2001 Aims of Healthcare  Safety  Effectiveness  Patient-centeredness  Timeliness  Efficiency  Equity

6. S5: November 10, 2006New Community, New Practice David B. Graham, MD 6 Institute for Healthcare Improvement (IHI) Modification of IOMs 6 Aims for Healthcare  No Needless Deaths  No Needless Pain or Suffering  No Helplessness  No Unwanted Waits  No Waste  ……For Anyone

7. S5: November 10, 2006New Community, New Practice David B. Graham, MD 7 Future of Family Medicine Annals of Family Medicine in 2004 “…brings together the enduring values of family medicine with new technologies and approaches for practices to better serve the needs of patients in the 21st century. It involves providing patients with a personal medical home emphasizing a patient- centered care approach that eliminates barriers to access. “ The Future of Family Medicine: A Collaborative Project of the Family Medicine Community. Ann Fam Med 2004 2: S3-S32.

8. S5: November 10, 2006New Community, New Practice David B. Graham, MD 8 Future of Family Medicine Patient-Centered practice  Open/Advanced Access  Advanced Information Systems Electronic Health Record Asynchronous Communication  Redesigned, more Functional offices  Focus on Quality & Safety  Community context

9. S5: November 10, 2006New Community, New Practice David B. Graham, MD 9 Movements to Improvement & Change Innovation Collaboratives Idealized Design of the Clinical Office Practice (IDCOP) Patient-Centeredness Idealized Teams Chronic Care Model Lean Production (Toyota model) NIH funded research ongoing

10. S5: November 10, 2006New Community, New Practice David B. Graham, MD 10 IHI evolution IDCOP Movement initiated by IHI in 1993?? IHI evolution 198619911998future Awareness EducationCollaboration & Redesign Full Scale

11. S5: November 10, 2006New Community, New Practice David B. Graham, MD 11 Patient-Centered What does it really mean? Can we define it for our patients? Can we define it for our practices? Can we define it for our learners? Activity: Small groups to define elements of patient-centeredness.

12. S5: November 10, 2006New Community, New Practice David B. Graham, MD 12 Shared Vocabulary Summary Patient’s perceived needs Daily task Data transparency Navigators Full scope from the call to exit Resident’s involvement Patient preference as customer – when, how, what Measurable outcomes Access based on patient demand Collaborative decision style Open-endedness in style Service industry Patient values in every interaction Patient-centered Communication

13. S5: November 10, 2006New Community, New Practice David B. Graham, MD 13 Patient-Centered IOMPatient-centeredness  “Providing Care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.” IHINo Helplessness FFM“… personal medical home emphasizing a patient-centered care approach…”

14. S5: November 10, 2006New Community, New Practice David B. Graham, MD 14 Patient-Centered STFM  63 web pages on STFM's website  95 sessions presented at STFM conferences  225 Family Medicine articles. AAFP  645 hits on aafp.org American Academy of Pediatrics (AAP)  1199 hits on aap.org American College of Physicians (ACP)  8357 hits on acponline.org

15. S5: November 10, 2006New Community, New Practice David B. Graham, MD 15 IOM 10 Rules for Patient Care 1. Care based on continuous healing relationships. 2. Customization based on patients needs and values. 3. Patient as the source of control. 4. Shared knowledge and free flow of information.

16. S5: November 10, 2006New Community, New Practice David B. Graham, MD 16 IOM 10 Rules for Patient Care 5. Evidence-based decision making. 6. Safety as a system priority. 7. The need for transparency. 8. Anticipation of needs. 9. Continuous decrease in waste. 10. Cooperation among clinicians. Crossing the Quality Chasm: A New Health System for the 21 st Century. Committee on Quality in Health Care in America, Institute of Medicine. National Academies Press: Washington DC, 2001.

17. S5: November 10, 2006New Community, New Practice David B. Graham, MD 17 Patient-Centered “Joint Principles of the Patient-Centered Medical Home.” July 2006 AAFP & ACP together and acknowledge AAP movements  Personal physician  Physician directed medical practice  Whole person orientation  Care is coordinated and/or integrated  Quality and Safety are hallmarks  Enhanced access  Payment systems (recognition)

18. S5: November 10, 2006New Community, New Practice David B. Graham, MD 18 New Practice University of Colorado at Denver and Health Sciences Center  Department of Family Medicine AF Williams Family Medicine Center Residency-Faculty practice Striving toward the New Model of Care

19. S5: November 10, 2006New Community, New Practice David B. Graham, MD 19 AF Williams Family Medicine Center Academic residency training clinical practice 18 residents (6-6-6) 14 faculty 5 NP/PA 20,000+ visits per year Previous location since 1991 Moving in November/December 2006

20. S5: November 10, 2006New Community, New Practice David B. Graham, MD 20 AF Williams Family Medicine Center Initial change efforts with Innovation Teams  approximately 2001  Lean Principles/ IDCOP Open Access Scheduling  January 2003 EHR started  November 2003 Asynchronous Communication  March 2005

21. S5: November 10, 2006New Community, New Practice David B. Graham, MD 21 Innovation and Improvement Teams Lead Team Front Office Team Back Office Team Provider Team Clinical Teams Residency

22. S5: November 10, 2006New Community, New Practice David B. Graham, MD 22 AFW – What has worked? Works well  Lead Team  Asynchronous communication Works “fair”  Open Access  Clinical Teams

23. S5: November 10, 2006New Community, New Practice David B. Graham, MD 23 What is missing? AFW transforming practice Community Linkage and interactions Partnering with a New Community

24. S5: November 10, 2006New Community, New Practice David B. Graham, MD 24 Stapleton Redevelopment

25. S5: November 10, 2006New Community, New Practice David B. Graham, MD 25 Stapleton Redevelopment

26. S5: November 10, 2006New Community, New Practice David B. Graham, MD 26 Stapleton Redevelopment

27. S5: November 10, 2006New Community, New Practice David B. Graham, MD 27 Stapleton Redevelopment Voters approve DIA 1990 Initial planning 1990 - 1995  Green Book 1995 Development selection 1993 - 1996 Stapleton Airport closes 1995 Community Building 2000  Construction begins 2000 Families move in 2003 

28. S5: November 10, 2006New Community, New Practice David B. Graham, MD 28 Stapleton Foundation Ideals  Working with others, we will strive to create a community that is seamlessly connected to surrounding neighborhoods as well as a community that becomes a sustainable model in education, employment, open space, housing, diversity and sustainable development. Principles  Neighborhood Connections  Lifelong Learning  Sustainable Development Funding

29. S5: November 10, 2006New Community, New Practice David B. Graham, MD 29 Greater Stapleton – the Community 5 Neighborhoods together Northeast Parkhill Parkhill North Aurora Neighborhood Association East Montclair Stapleton

30. S5: November 10, 2006New Community, New Practice David B. Graham, MD 30 Greater Stapleton – the Community

31. S5: November 10, 2006New Community, New Practice David B. Graham, MD 31 AFW moving to Stapleton

32. S5: November 10, 2006New Community, New Practice David B. Graham, MD 32 AFW physical redesign

33. S5: November 10, 2006New Community, New Practice David B. Graham, MD 33 AFW physical redesign details Borrowed concepts from many places  IHI – IDCOP  Lean concepts  Safety and functionality at the heart of design Co-location of people and tasks Standardized exam spaces Small waiting room – all activity centralized Clinica Campesina experience

34. S5: November 10, 2006New Community, New Practice David B. Graham, MD 34 AFW physical redesign details Pod Work zone 9 “standard” exam rooms

35. S5: November 10, 2006New Community, New Practice David B. Graham, MD 35 Stapleton becoming a reality

36. S5: November 10, 2006New Community, New Practice David B. Graham, MD 36 Stapleton becoming a reality

37. S5: November 10, 2006New Community, New Practice David B. Graham, MD 37 AFW planned concepts – day 1 Personal Health Assessments Integrated Registry and practice data Xpress Patient Services  Electronic Check-in  Forms emailed prior to visit  My Doctor’s Office Printers in every room Extended hours (Saturday AM) Emphasis on comfortable exam rooms

38. S5: November 10, 2006New Community, New Practice David B. Graham, MD 38 AFW planned concepts – day 1 Community driven initiatives Continuous evaluation Collaborative & integrated healthcare  Integrative Medicine  Psychiatry  Pharmacy links  Other specialists

39. S5: November 10, 2006New Community, New Practice David B. Graham, MD 39 AFW planned concepts – year 1-3 Community Advisory Council Health Information Resource Center Full transparency of data  Web portal for viewing personal medical record Dual-zone WiFi connectivity  Patient education materials on desktop Continuous evaluation  Iterative improvement and innovation Community driven initiatives

40. S5: November 10, 2006New Community, New Practice David B. Graham, MD 40 AFW outreach to the Community Focus Groups 3 year partnership with the Stapleton Foundation Stapleton 2040 School based & Home care programs Other partners  YMCA  Johnson & Wales University  Denver Parks and Recreation  Ongoing recruitment

41. S5: November 10, 2006New Community, New Practice David B. Graham, MD 41 CU Center for Healthy Living Healthy People Healthy Neighbors Healthy Future

42. S5: November 10, 2006New Community, New Practice David B. Graham, MD 42 Stapleton Foundation 2006 Neighborhood Connections Lifelong Learning Sustainable Development Healthy Neighborhoods  Healthy Living  Neighborhood connections

43. S5: November 10, 2006New Community, New Practice David B. Graham, MD 43 New Model Transformation New Community New Practice Can the Chronic Care Model help?

44. S5: November 10, 2006New Community, New Practice David B. Graham, MD 44 Chronic Care Model (CCM) "Improving Chronic Illness Care (ICIC) is a national program supported by The Robert Wood Johnson Foundation with direction and technical assistance provided by Group Health Cooperative's MacColl Institute for Healthcare Innovation". Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

45. S5: November 10, 200645 ICIC Chronic Care Model Resources and Policies Community Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Health Care Organization Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Improved Outcomes CC

46. S5: November 10, 2006New Community, New Practice David B. Graham, MD 46 Patient-Centered and the CCM

47. S5: November 10, 2006New Community, New Practice David B. Graham, MD 47

48. S5: November 10, 2006New Community, New Practice David B. Graham, MD 48 Distractions and Road Blocks Payment systems (reimbursement?) Clinical inertia Systems inertia Lack of community linkages Time “…but that is the way we have always done it.”

49. S5: November 10, 2006New Community, New Practice David B. Graham, MD 49 Maintaining the momentum Difficult to sustain change without support and leadership at ALL levels of the organization. Plan regular meetings and always keep them. Small PDSAs instead of waiting for the big event. Involve all members of the care team.

50. S5: November 10, 2006New Community, New Practice David B. Graham, MD 50 Objectives Discuss elements of the New Model of practice that enhance patient- centeredness. Integrate concepts of Chronic Care Model (CCM) into clinical practice and education. Utilize available resources for practice redesign and transformation.

51. S5: November 10, 2006New Community, New Practice David B. Graham, MD 51 Resources Institute of Medicine  www.iom.edu AAFP and STFM Institute for Healthcare Improvement  www.ihi.org AAMC – Institute for Improving Clinical Care  www.aamc.org/patientcare/iicc/ Improving Chronic Illness Care  www.improvingchroniccare.org/ www.improvingchroniccare.org/ Stapleton Foundation  www.stapletonfoundation.org

52. S5: November 10, 2006New Community, New Practice David B. Graham, MD 52 Thank you Contact me with questions or comments:  David.Graham@uchsc.edu David.Graham@uchsc.edu Remember Seminar evaluations Slides available at Family Medicine Digital Resource Library (FMDRL)  www.fmdrl.org Be leaders for Patient-Centered change, improvement and transformation.