1. Medical Home and Disease Management: Convergence Synergy National Medical Home Summit, 2009 Jaan Sidorov, MD, MHSA – Sidorov Health Solutions Doug Berkson, MPH – Health Dialog

2. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 2 Agenda Potential Areas of Collaboration and Synergy in Traditional Disease Management and Patient Centered Medical Home Lessons from One Disease Management Organization: Integrated Care Management (ICM) Data aggregation and analytics Practice-based care management Measurement Medical Neighborhood Oberservations and Thoughts on Current State of Patient-Centered Medical Home

3. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 3 1. Data Aggregation and Analytics 2. Reach and Engage 4. Measurement 3. Intervention Integrated Care Management: New Model (Medical Home?) Traditional Disease Management Model Vendor primarily responsible for all components Integrated Care Management Model Providers/Practices may take role in any or all components

4. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 4 ICM and Medical Home Overlap PPC 1: Access and Communication PPC 2: Patient Tracking and Registry Functions PPC 3: Care Management PPC 4: Patient Self-Management Support PPC 5: Electronic Prescribing PPC 6: Test Tracking PPC 7: Referral Tracking PPC 8: Performance Reporting and Improvement PPC 9: Advanced Electronic Communications NCQA Standards Medical Home Standards

5. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 5 1.Data Aggregation & Analytics: Registries are not enough… Creating Actionable Information from Data Aggregate data across sources, practices and health plans Utilize predictive models for risk identification and stratification Create a robust population management tool

6. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 6 2. Reach & Engage Traditional Model Sophisticated engagement technologies and strategy Community Grid Outbound calls Interactive Voice Response Mail Email Integrate Care Model – Practice-based Well-established relationships Point-of-care engagement Direct referrals

7. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 7 3.Intervention A nurse in the office with a phone & chronic condition disease guidelines is not enough… Integrated Care Management: physician-based and/or directed Care Managers/Health Coaches can be practice-based or remote- based (hybrid model) Training Motivational interviewing, & behavior change theory Chronic condition management Care coordination and transitions Shared-decision making Infrastructure and Tools Technology platform – activity tracking and content functionality Decision aides for Preference Sensitive Conditions Evidence-based education and self care materials Implementation & Operations

8. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 8 4. Measurement: Quality alone is insufficient.

9. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 9 4. Measurement - its not just about what happens in primary care… Primary Care Cardiologist E $7,456 Cardiologist E $7,456 Cardiologist D $5,508 Cardiologist D $5,508 Cardiologist C $4,749 Cardiologist C $4,749 Cardiologist B $4,074 Cardiologist B $4,074 Cardiologist A $2,557 Cardiologist A $2,557 Endocrinologist A $2,203 Endocrinologist A $2,203 Endocrinologist B $2,900 Endocrinologist B $2,900 Endocrinologist C $3,161 Endocrinologist C $3,161 Endocrinologist D $3,591 Endocrinologist D $3,591 Endocrinologist E $4,702 Endocrinologist E $4,702 Hospital A $7,244 Hospital A $7,244 Hospital A $9,777 Hospital A $9,777 Hospital A $10,767 Hospital A $10,767 Unwarranted Variation in Quality – Preference - Efficiency

10. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 10 4. Measurement – from the Medical Home to the Medical Neighborhood Medical Home ----------------------- Coordinated Primary Care Medical Home ----------------------- Coordinated Primary Care Cardiologist A $2,557 Cardiologist A $2,557 Endocrinologist A $2,203 Endocrinologist A $2,203 Hospital A $7,244 Hospital A $7,244 High Quality Patient preferences Efficient care No more than necessary High Performing Community

11. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 11 Agenda Potential Areas of Collaboration and Synergy in Traditional Disease Management and Patient Centered Medical Home Lessons Learned by One Disease Management Organization Utilizing data aggregation, analytics/health informatics, and health coaching to support Medical Homes: Data aggregation and analytics Practice-based and/or Physician-directed care management Measurement PCMH in the context of Unwarranted Variation Observations and Thoughts on Current State of Patient-Centered Medical Home

12. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 12 Observations and Thoughts on the Current State of Medical Homes Fanfare Scrutiny Disappointment Reality DM and PCMH may have differing timelines Many models, few Medical Homes Most current pilots/demos look more like P4P Insufficient reimbursement Health Plans Employers Variable recognition or embracement by providers of the degree of change & collaboration required for transformative next generation Medical Homes

13. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 13 Questions?