1. Developing Community Partnerships with Primary Care Judith Schaefer, MPH MacColl Institute Diabetes Alliance of Idaho Fall Meeting November 5, 2010

2. Radical Patient Centeredness (1) “The needs of the patient come first.” (2) “Nothing about me without me.” (3) “Every patient is the only patient.”

3. Patient Hospital Services Primary Care Social Services Specialists Mental Health Delivery System Mismatch with Determinants of Premature Death… This is how it looks now… Public Health Hospital Services Specialists Financing Community Family

4. Patient Driven Care Patients are the most important factor in their own outcomes (and need to do the heavy-lifting) Patients are the experts in themselves –Health 2.0 is a “Reformation” –What is role of Care Team? –What is role for community? Services designed from patient point-of- view to meet patient needs and preferences

5. Patient Hospital Services Family Clinician Practice Friends and Family Specialists Community The Medical Home: It Depends on Your Point-of-View… The “empowered patient” view…a better match? Neighborhood Gym/ Recreation Place of Worship Workplace Internet Social Media

6. A process A way of seeing Medical Home Conceptual model/ philosophy Specific delivery system definition Designation through formal recognition

7. Joint Principles of a Medical Home Continuous relationship Quality & Safety Enhanced access Integrated & coordinated care Whole person orientation Payment Reform American Academy of Family Physicians. Joint principles of the Patient-Centered Medical Home. Del Med J. Jan 2008;80(1):21-22.

8. Medical Home: Common Themes Reinvigorating Core Attributes of Primary Care (access, longitudinal relationships, comprehensiveness, coordination) Coordination of Care Across Settings (access to education/support programs and specialty care,) System supports for Chronic Illness Care (decision support, practice redesign, self mgmt, community links) Advanced information technologies (EMRs, registries, reminders, patient portals) Supportive payment methods

9. Medical Home Conveners Purchaser CoalitionPatient Centered Primary Care Collaborative www.pcpcc.net Private PayersGroup Health, Geisinger, Care Oregon Public PayersMedicare Demo, many state Medicaid agencies e.g. Community Care of North Carolina Innovative State ExecutivesPennsylvania, Massachusetts FoundationsCommonwealth Fund: Safety Net Medical Home Initiative, Robert Wood Johnson Foundation: IPIP Multistakeholder Collaboratives Maine, Colorado, Greater Cincinnati Aligning Forces for Quality Public Health DepartmentsWashington

10. Medical Neighborhood Behavioral Health Integration Care Coordination & Care Transitions Patients as Partners Population Health & Clinical Care Mgmt

11. Imperative of Integration “1 of 15 programs showed significant reduction in hospitalizations.” “Only two programs appear to have made clear improvements in the quality of preventive care.” “The Evaluation of Medicare Coordinated Care Demonstration: Findings for the First Two Years.” (2007) Brown, Peikes, Chen, Ng, Schore, Soh.

12. Group Health Research Institute Annual Report. (2008)

13. Programs - Role in PCMH NCQA accreditation elements –PC Practice “must have’s” Coordination Self-management education and support Tailored and culturally appropriate care

14. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Organization of Health Care Planned Care Model Emphasize the patient's central role. Use effective self- management support strategies that include assessment, goal- setting, action planning, problem- solving and follow-up. Organize resources to provide support

15. Collaborative Self-Management Support: Core Competencies Relationship Building Assessing patients’ needs, expectations and values Information Sharing Collaborative Goal Setting Action Planning Problem Solving Ongoing Follow-up

17. Bringing the Community Into the Care Team Community health workers - diverse pops Embedding behavioral health in primary care Bringing specialist health education, CDEs Engaging other patients and families with the team, and with each other Group Visits Providing links to vetted community resources

18. Bringing Care into the Community Peer to peer support programs Patient portals and chat groups/blogs Collaborating with community organizations – ADA, Farmer’s market, Americorp Collaborating on empowerment workshops Forging partnerships with other healthcare deliverers

20. Chronic Disease Self-Management Traditional community based programs for many years –Over 600 participants in past 2 years Programs targeted to people with particular chronic illness (e.g. heart failure) Practice-based programs Employer-based programs

21. Bringing Health Care to the Community MaineHealth Learning Resource Centers –Community health education centers located in health care facilities –Public educational sessions –Chronic Disease Self-Management Workshops (Lorig Model) –Shared Decision Making Partnering with NAMI for depression gps

22. Humboldt County Aligning Forces for Quality Chronic Care Model elements: IPA-led community wide improvement effort ─Health IT: Chronic Disease registry ─Decision Support: E-referrals, disease specific guidelines ─Self-Management Support: Health Education Alliance ─Delivery System Design: Care Support Primary Care Renewal: IPA-led “build your own medical home” collaborative Care Support of high-risk patients – harm-reduction strategy Our Pathways to Health: peer-led SMS “Kate Lorig Model” Care Transitions: RN-led hospital program for ED and post- admit patients Comparative Performance Reporting: “Triple Aim” ─Population Health: HMO and PPO Measures (HEDIS) ─Patient Experience: CAHPS (PAS in CA) ─Efficiency Measures: Total Cost of Care, ED visits, bed days, generics, imaging for LBP, 30-day readmits, ─evidence-based cervical cancer screening

23. Self-Management Support “Our Pathways to Health” Patient Education ─Information and skills are taught ─Usually disease-specific ─Assumes that knowledge creates behavior change ─Goal is compliance ─Teachers are health care professionals ─Didactic Self-Management ─Skills to solve patient- identified problems are taught ─Skills are generalizable to all chronic conditions ─Assumes that confidence yields better outcomes ─Goal is to increase self- efficacy ─Teachers can be professionals or peers ─Interactive. adapted from Bodenheimer, Lorig, et al JAMA 2002;288:2469.

24. Primary Care Renewal “The only way to know is to try…” “Build Your Own Medical Home” Defining “key principles” allows each to create the medical home ideas and practices that “work for them” and might be useful to others…

25. Patient-centered Medical Home Key Features: 1.Engaged leadership 2.Quality improvement strategy 3.Empanelment 4.Patient-centered interactions 5.Organized, evidence-based care 6.Care coordination 7.Enhanced access 8.Continuous, team-based health relationships

26. The pitfalls of fragmented care 1.You don’t know the people to whom you are referring patients. 2.Specialists complain about the information you send with a referral. 3.You don’t hear back from a specialist after a consultation. 4.Your patient complains that the specialist didn’t seem to know why s/he was there. 5.A referral doesn’t answer your question. 6.Your patient doesn’t come back to see you after a consultation. 7.A specialist duplicates tests you have already performed. 8.You are unaware that your patient was seen in the ER. 9.You were unaware that your patient was hospitalized.

27. The good old days PCPs and specialists talking over patients in the hospital cafeteria.

28. Poor Coordination: Nearly Half of Consumers Report Failures to Coordinate Care Percent U.S. adults reported in past two years: Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008. No one contacted you about test results, or you had to call repeatedly to get results Test results/medical records were not available at the time of appointment Your primary care doctor did not receive a report back from a specialist Any of the above Doctors failed to provide important medical information to other doctors or nurses you think should have it Your specialist did not receive basic medical information from your primary care doctor

29. Doctors’ Reports of Care Coordination Problems Percent saying their patients “often/sometimes” experienced: AUSCANGERNETHNZUKUS Records or clinical information not available at time of appointment 28421116283640 Tests/procedures repeated because findings unavailable 102057142716 Problems because care was not well coordinated across sites/providers 39462247496537 Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

30. Commonwealth Survey of Primary Care MDs: Percent reporting that they receive information back for “almost all” referrals (80% or more) to Other Doctors/Specialists Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

31. Fragmentation of Care Provider referral networks have become depersonalized. Critical information for referrals and transitions are often lacking or missing, which distresses patients and unhelpful (or worse) for providers. Care coordination is “the deliberate integration of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.” Care coordination refers to activities and interventions that attempt to reduce fragmentation and improve the quality of referrals and transitions.

32. What constitutes a high quality referral or transition? Safe Planned and managed to prevent harm to patients from medical or administrative errors. Effective Based on scientific knowledge, and executed well to maximize their benefit. Timely Patients receive needed transitions and consultative services without unnecessary delays. Patient- centered Responsive to patient and family needs and preferences. Efficient Limited to necessary referrals, and avoids duplication of services. Equitable The availability and quality of transitions and referrals should not vary by the personal characteristics of patients.

33. Care Coordination in PCMH Practices Link patients with community resources to facilitate referrals and respond to social service needs. Have referral protocols and agreements in place with an array of specialists to meet patients’ needs. Proactively track and support patients as they go to and from specialty care, the hospital, and the emergency department. Follow-up with patients within a few days of an emergency room visit or hospital discharge. Test results and care plans are communicated to patients/families. Provide care management services for high risk patients.

35. Key Changes 1.Assume accountability 2.Provide patient support 3.Build relationships and agreements 4.Develop connectivity

36. #1 Assume Accountability Initiating conversations with key consultants, ERs, hospitals, and community service agencies. Setting up an infrastructure to track and support patients going outside the PCMH for care.

37. #2 Provide Patient Support: Three levels of support Care Coordination Clinical Follow-up Care Clinical Care Management

38. Logistical Clinical Monitoring Self-mgt Support & Medication Mgt. % of panel <5% 10% 20% Care Coordination Clinical Follow-up Care Clinical Care Management

39. What’s involved in providing logistical support? Helping patients identify sources of service— especially community resources Helping make appointments Tracking referrals and helping to resolve problems Assuring transfer of information (both ways) Monitoring hospital and ER utilization reports Managing e-referral system

40. #3 Build Relationships and Agreements Primary care leaders initiate conversations with key specialists and hospitals around mutual expectations. Specialists have legitimate concerns about inappropriate or unclear reasons for referral, inadequate prior testing etc. Agreements are sometimes put in writing or incorporated into e-referral systems.

41. #4 Develop Connectivity Most of the complaints from both PCPs and specialists focus on communication problems— too little or no information, etc. Evidence indicates that standardized formats increase provider satisfaction. Three options for more effective flow of standardized information—shared EMR, e- referral, structured referral forms.

42. Connect with Programmatic Resources Hospital or community based programs for diabetes education Peer led groups that support self management Transition support across care sites Healthy eating and physical activity resources

43. Challenges Remaining What should live in primary care? Linking patients to programs Create supportive systems Incentives & culture change

44. www.improvingchroniccare.org Contact us: Thanks