1. Creating an ideal practice
L. Gordon Moore
AAFP/STFM
November 2006

2. Objectives Explain the components of an ideal practice
Understand how innovation approaches in the internet helps practices and patients with chronic conditions
Describe outcomes achieved by some ideal practices

3. Primary Care Score: 2 = Stronger From Barbara Starfield, MDUK SP US
Primary Care Score: 2 = Stronger
From Barbara Starfield, MD

4. Barriers to primary care
Conclusions: The disproportionate ED utilization for chronic ACS conditions by black persons and Medicaid patients does not appear to be explained by either differences in disease prevalence or disease severity.
Follow-up arrangements for black persons, Medicaid, and uninsured patients suggest that they are less likely to have ongoing primary care. Barriers to primary care appear to contribute to the higher ED and hospital utilization rates seen in these groups.
Oster, Ady MD; Bindman, Andrew B. MD Medical Care Volume 41(2), February 2003, pp

5. Cost of inadequate primary care
Abstract: The quality of care received by Medicare beneficiaries varies across areas. We find that states with higher Medicare spending have lower-quality care. This negative relationship may be driven by the use of intensive, costly care that crowds out the use of more effective care.
One mechanism for this trade-off may be the mix of the provider workforce: States with more general practitioners use more effective care and have lower spending, while those with more specialists have higher costs and lower quality. Improving the quality of beneficiaries' care could be accomplished with more effective use of existing dollars.
Baicker K. Chandra A. Health Affairs. Suppl Web Exclusive:W184-97, 2004.

6. If you get it, is it good enough?
RESULTS: Participants (a random sample of adults living in 12 metropolitan areas in the United States) received 54.9 percent of recommended care.
CONCLUSIONS: The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted.
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. New England Journal of Medicine, June 26, 2003.

7. What makes care “good”?
Having trust in cancer information from the doctor or other health care professional was most predictive of being up to date.
Other predictive factors include having a desire for cancer information from personalized reading materials and using the Internet from home.
Ling BS. Klein WM. Dang Q. Journal of Health Communication. 11 Suppl 1:181-90, 2006.

8. Patient perspective of “why we don’t show up”
Delay for appointment:
“I can’t get in when I want/need to get in”
Respect:
“You make me wait in your office”
“You don’t take the time to listen to me”
Transportation and child care were logistical barriers, but respondents noted they could be overcome.
Lacy, Paulman, Reuter, Lovejoy. Ann Fam Med 2004; 2:

9. The paradigm shift adapted from Bodenheimer et al, JAMA, 2002
Traditional Model
Collaborative, patient centered care
Diagnosis
Treatment
Roles in care:
Physician is the expert and caregiver-
creates the treatment plan.
Mechanism of change
Patient compliance (external motivation)
Response to gaps in adherence/outcomes:
Poor patient compliance
Style emphasis: Objective detachment
Discovery
Dialogue
Shared expertise; patient as caregiver
Co-creation of plan
Mechanism of change:
Building understanding and confidence
Treated as opportunities for learning,
problem solving and redesign of plans
Style emphasis: engaging, warm, curious, supportive, hopeful

10. Concerns, Socioeconomics, Obstacles to Self-Care
For Most Health Problems
the TOP Is Attained Only When The Patient is a Collaborating Partner
I Receive
Exactly The Care
I Want And Need
Exactly When And How
I Want And Need It
Result
Practice Redesign
Patient Portals
Registry
Access, Reliability
Care Planning
Patient Activation and Support
Shared Decision-Making
Action
Problem-Solving
Timely-Feedback of Actionable Information
Summary of Tailored Information
Function, Symptoms,
Burden Of Illness,
Concerns, Socioeconomics,
Obstacles to Self-Care
Prevention
Chronic Disease
Patient
Experience
Measures
Clinician,
Health System
What is the Matter?
Patient,
Community
What Matters
Patient/Clinician Divide

11. Closing the gap
Wasson, Johnson, et al. JACM Vol. 29, No. 3, pp. 199–206

12. Key practice components
Moore LG, Wasson JH, JACM Vol 29, No 3, pp

13. In Case a “Multi-Factorial,” Left and Right Pyramid Perspective is Not Complicated Enough We have Diseases!
Some physician office practices are implementing strategies to improve measured performance for the care of many diseases.
However, a disease-by-disease focus is inherently inefficient.

14. Fortunately, Most Patients Fit Categories for Generic Planned Care

15. Components of Generic Planned Care
Practices find out what matters to patients - (patient-centered care);
Practices help patients become more confident self-managers by using generic problem-solving approaches common to most health problems - (collaborative care); and
Practices make changes in their function so that this patient-centered, collaborative care is delivered efficiently, reliably, and effectively.

16. Taking Action on the What We Know About PCCC and How to Attain It
Screen all
Design across-the-board solutions
Open access scheduling
High continuity
Efficient processes for patient and information flow
Access to very good information
Stepped self-management support based on patient need

17. Motivated Traditional Practices
IMPs Compared to Other Practices (for similar patients with common chronic problems)
IMPs
(n=450)
Motivated Traditional Practices
(n=1200)
National Sample
(N=25,000)
On Same Page
Doctor or Nurse Aware of Feelings
87%
72%
51%
Information Exchange
Excellent or Very Good Information
83%
68%
Care Processes
Very Easy Access
64%
46%
52%
Nothing Needs Improvement
55%
42%
40%
Overall Patient-Centered
“I receive exactly the care…
60%
25%

18. Where we’re going www.IdealMicroPractice.org
Incubators
Pilots for new training, finances
I’ll post the presentation to my web site: