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Beyond the Medical Home: Teaching and Interdisciplinary Care Conferences Group Health Family Medicine Residency Seattle Sara Thompson, MD - Program Director.

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Presentation on theme: "Beyond the Medical Home: Teaching and Interdisciplinary Care Conferences Group Health Family Medicine Residency Seattle Sara Thompson, MD - Program Director."— Presentation transcript:

1 Beyond the Medical Home: Teaching and Interdisciplinary Care Conferences Group Health Family Medicine Residency Seattle Sara Thompson, MD - Program Director Carl Morris, MD - Associate Program Director

2 Outline PCMH Background Group Health Residency’s Medical Home TIC sessions Next steps Discussion

3 3 Medical Home – A Brief Historic Review Started in pediatrics – initially in the1960’s, expanded in 2002 2004 Future of Family Medicine 2006 ACP 2007 Joint principles of the patient-centered medical home from AAFP, AAP, ACP and AOA NCQA P4 (Preparing the Personal Physician for Practice) – 6 year, 14-residency project with each residency incorporating some aspect of the medical home TransforMed - National Demonstration Project with 36 clinical practices

4 4 2007 Joint Principles of the PCMH Personal physician Physician-directed practice Whole person orientation Coordinated and integrated care Quality and safety Enhanced access Payment reform

5 5 Group Health – a Brief Introduction Integrated staff model HMO in Washington and western Idaho established in the 1940s At present: –>500,000 patients –26 primary care clinics: 81% FPs, 4% internists, 15% pediatricians 4 specialty clinics, 6 UC/ER, 7 hospitals (contracted) Pharmacy and lab integrated EMR Guidelines, patient registries Consulting nurse (24/7)

6 6 GH Medical Home: Background 2002-2006 a series of reforms including –Same day appointing (open access) –New EMR –Online Patient access (email to provider, labs, record) Results –Improved patient access/satisfaction –Increase MD workload –Decreased MD satisfaction –Increased utilization: ER, specialty, hospital –Reductions in quality of care

7 Houston, we have a problem 7

8 8 GH Medical Home: Core Principles Relationship to provider is core Physician leads the clinical care Care is comprehensive Patient-centered access: 24/7, electronic Align clinical and business systems

9 9 GH Medical Home Pilot Changes: Structural: decrease panel size, lengthen visit time, schedule time for phone and e-visits Point of care: use of registries, flow staff reviewed and recorded needs for chronic disease management and preventive care Patient outreach: by pharmacy and RN staff Management structure/philosophy: Rapid process and improvement workshops

10 10 GH Medical Home Pilot: Success declared at one year Cost neutral Improved patient satisfaction Improved quality of care (HEDIS) measures Improved provider satisfaction 2009 Pilot expands to other clinics including the residency 2010 Pilot results at two years showed quality and satisfaction measures persisted and there were cost savings.

11 Group Health Residency Medical Home

12 12 GH Residency Medical Home: Implementation Schedule template changes Training changes –Team structure –Virtual visit curriculum/evaluation –RRC Innovation: # continuity visits

13 GH Residency Medical Home: Outcomes Patient satisfaction Quality measures Resident satisfaction RRC Innovation Proposal accepted 13

14 Beyond the Medical Home: TIC sessions Components Curricular/clinical gaps Design Implementation Tools Outcomes 14

15 Beyond the Medical Home: TIC sessions Curricular/clinical gaps: Population-based care Identification with panels Chronic disease management Prospective approach Team integration 15

16 Beyond the Medical Home: TIC sessions Design: Curricular content Time Standard structure 16

17 BlockTeaching TopicClinical Review 1DM 2 3HTNHTN, Psych Dx 4Cancer screeningCancer screening, CHF 5Chronic PainChronic Pain, immunizations 6COPDCOPD, DM 7CHF/HTNCHF, Med. Mgmt 8Depression/anxietyPsych Dx, 9Subst abuse: etoh/tobaccoSubstance abuse, Chronic Pain 10CADCAD, DM 11Immunizations 12End of Life CareCancer Screening, CHF 13Quality reviewMisc prevention, panel transfers Curriculum Design

18 TIC Sessions: Structure Sample agenda 1:00-2:00COPD Overview 1.Case-based discussion 2.Review of chronic disease care plans 3.Review care management tools: PCER 4.Review of DM work 2:00-4:45TIC work on COPD and DM 1.Review PCER for COPD unmet care 2.Review care of COPD patients 3.Review/create chronic care plans 4.Outreach to patients 5.Help practice partner 6.Outreach for DM: focus on Hgba1c>9.0 7.Review PCER for all unmet care needs 4:45-5:00Discussion 18

19 TIC Sessions: Tools Guidelines: GH, others Systematic Reviews Planned Care Exception Report (PCER) EPIC panel reports TIC tools 19

20 Pre-visit Work: The PCER (Patient Care Exception Report)

21 TIC Tools Chronic Disease Plans Dot phrases Outreach tools Clinical processes 21

22 MEDICAL TREATMENT PLAN FOR DIABETES *Good care of diabetes decreases the chance of heart, eye and kidney problems, problems with circulation in your legs, and loss of sensation in your feet. DESIRED GOALS: * Blood sugar: {CHRONIC DISEASE DM:20042} * Blood Pressure: Less than 130/80. * Cholesterol: LDL (bad cholesterol) less than 100. TREATMENT PLAN: * Exercise: *** * Diet: *** * Home blood sugar monitoring: {:20039} * Medication Changes this visit: {CHRONIC DISEASE MED CHANGES:20660} LAB TEST PLAN: * Hemoglobin A1c every 3-6 months: Next test *** * Cholesterol, liver and kidney function every year: Next test *** * Eye exam every 1-2 years: Next test *** UPCOMING APPOINTMENTS: * *** WHO TO CONTACT: Contact your clinic health team by email on MyGroupHealth or phone (206) 326-3530. Claudia Fairfax is our clinic nurse. Stuart O'Brochta is our clinic pharmacist. You can call the consulting nurse at 206-901-2244 or toll-free at 1-800-297-6877 if you have urgent questions after clinic hours.

23 TIC Tools CANCER PREVENTION LETTER I am interested in not only helping you feel better when you are sick, but also in keeping you from getting sick in the first place. In the spirit of maintaining your good health, our computer system indicates that you are due for the following: {OUT LTR NEEDS:20956} Take care,.me

24 TIC Tools ESTABLISHING CARE – DIABETES My name is ***, MD. I have been assigned as your new primary care provider. I am looking forward to getting to know you. I am writing to encourage you to schedule either a telephone or clinic visit so that we can get to know each other. I have reviewed your chart and would like to help you with your diabetes care as well as any other concerns you have. Please call 206 326 3530 and schedule an appointment with me at your convenience. Take care,.me

25 Beyond the Medical Home: TIC sessions Outcomes: Panel identification Team orientation Quality Satisfaction 25

26 2009-2010 HEDIS Measures Mar 09Mar 10Trend ABX Adult Acute Bronchitis65.4%36.4% 29.0% Well-Child 3-6 YO50.0%75.0% 25.0% Screen: Colorectal Cancer (NEW)38.3%60.1% 21.8% Postpartum Care56.7%78.2% 21.5% DM: HbA1c>9.051.5%32.5% 19.0% ASA: Ace for CAD63.0%75.6% 12.6% DM: HbA1c Test78.8%88.3% 9.5% Well-Care Adolescent27.3%36.1% 8.8% ASA: Ace for DM68.4%75.4% 6.9% IET: Engagement9.8%16.7% 6.9% Screen: Breast Cancer Total50.3%56.1% 5.9% DM: BP <140/9054.5%59.7% 5.2% CAD: Chol Mgt-LDL Screen85.7%90.0% 4.3% DM: LDL Screen72.7%76.6% 3.9% ASA: Statin for CAD77.8%80.5% 2.7% Prenatal Care83.3%85.9% 2.6% High Blood Pressure50.6%52.4% 1.8% Screen: Cervical Cancer75.5%76.9% 1.3% Asthma Appropriate Meds83.3%84.6% 1.3%

27

28 GH Residency Medical Home: Outcomes: Patient Satisfaction Patient Satisfaction –One year pre and post results –Improvement in all categories 28

29 Patient Satisfaction

30 TIC sessions: Next Steps Re-prioritization of clinic Increased team focus Focus clinical topics Integrate process into daily work Further evaluation 30

31 31 Discussion How might this work in other programs Opportunities Possible barriers and pitfalls

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