1. MEANINGFUL USE AND HEALTH CARE INNOVATION CONFERENCE Duke Energy Center Cincinnati, OH 16 March, 2012 New Models of Care: Understanding Medical Homes, ACO’s, & More Robert Graham, MD Director, National Program Office Robert Wood Johnson Foundation’s Aligning Forces for Quality Program Department of Health Policy, George Washington University Robert.graham@gwumc.edu and Adjunct Professor, Department of Family & Community Medicine University of Cincinnati College of Medicine grahamj3@uc.edu

2. Superb Access to Care Patients can easily make appointments and select the day and time. Waiting times are short. eMail and telephone consultations are offered. Off-hour service is available. Patient Engagement in Care Patients have the option of being informed and engaged partners in their care. Practices provide information on treatment plans, preventative and follow-up care reminders, access to medical records, assistance with self-care, and counseling. Clinical Information Systems These systems support high-quality care, practice- based learning, and quality improvement. Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments. Care Coordination Specialist care is coordinated, and systems are in place to prevent errors that occur when multiple physicians are involved. Follow-up and support is provided. Team Care Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals (including BH specialists). Duplication of tests and procedures is avoided. Patient Feedback Patients routinely provide feedback to doctors; practices take advantage of low- cost, internet-based patient surveys to learn from patients and inform treatment plans. Publicly available information Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs. 8 Source: Health2 Resources 9.30.08 Defining the Medical Home

3. Process & Structure Change Quality Improvement NCQA X Y PCMH Changing who you are Changing what you do Team Based Prospective Care Culture Change © R. Graham, MD 2011

4. Results to Date: ED Visits  Hospitalizations  Re-hospitalizations (all cause; 30-day)  % Generic prescriptions  Patient satisfaction  Staff & physician satisfaction 

5. PCMH in Tri-State 2009-2012 Pilots: – Group Health Associates-Springdale-Level 3 – Highland Family Healthcare-Level 3 – Mercy Health Physicians-Fairfield Family Medicine -Level 3 – Queen City Physicians-Hyde Park-Level 3 – St. Elizabeth Physicians-Williamstown-Level 3 – TCHMA-Internal Medicine 334-Level 1 – The Family Medical Group-Level 3 – TriHealth Physician Practices-Anderson-Level 3 – UC Health-Union Center-Level 3 – UC Health- Tylersville- Level 3 – UC Health Montgomery-Level 3 Co-Pilots: – Mercy Health Physicians-Fairfield IM & Rheumatology-Level 3 – The Health Care Connection-Lincoln Heights-Level 2 – Lisa Larkin, MD & Associates-Level 3 – Maineville Family Physicians-Level 1 – Queen City Physicians-Western Ridge-Level 3 – Queen City Physicians-Madeira-Level 3 – Queen City Physicians-Western Hills-Level 3 – Winton Hills Medical Center-Level 1 – Wright State Family Medicine Cohort III: – Crossroad Health Center – Mercy Health Physicians-Blue Ash – Mercy Health Physicians-Dent Crossing – Mercy Health Physicians-Eastgate – Mercy Health Physicians-Forest Park – Mercy Health Physicians-Milford – Mercy Health Physicians-Mt. Airy – Mt. Airy Medical Arts – Primary Health Solutions – St. Elizabeth Physicians-Covington – Summit Family Physicians – TCHMA-Madeira – TCHMA-Mt. Auburn – UC Health- Forest Park – UC Health- IM Faculty Practice – UC Health-Med-Peds – UC Health -Ruther – UC Health-Trenton