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A Tale of Two Cities: PCMH Residency Implementation Strategies Residency Program Solutions April 2011 A Tale of Two Cities: PCMH Residency Implementation Strategies Residency Program Solutions April 2011 Tim Munzing, MD, Carl Morris, MD & Bobby Davari, MD Kaiser Permanente Orange County and Group Health Seattle

Objectives o o List the Joint Principles of the PCMH Describe multiple components of Objectives o o List the Joint Principles of the PCMH Describe multiple components of health information technology in PCMH Discuss quality and safety benefits of the PCMH Formulate ideas how PCMH can be implemented within the Family Medicine residency program of attendees

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

Family Medicine o o o Family Physicians Bring Value and Access for the U. Family Medicine o o o Family Physicians Bring Value and Access for the U. S. Family Medicine is a specialty of complexity and relationships The Patient Centered Medical Home (PCMH) Challenges and Opportunities Optimism for the Future

Equity effects of primary care o o Improves self-rated health Reduces disparities Reduces effects Equity effects of primary care o o Improves self-rated health Reduces disparities Reduces effects of income inequality Reduces: n All-cause mortality n Cause specific mortality: Asthma, pneumonia, CAD, emphysema Starfield B et al. Milbank Quar 2005; 83: 457 -502

Time Requirements o o o 10. 6 hrs/day – chronic conditions 1 7. 4 Time Requirements o o o 10. 6 hrs/day – chronic conditions 1 7. 4 hrs/day – preventive services 2 Patient agenda? Acute care? Administrative issues? 1. Østbye T. Ann Famed Med 2005; 3: 209 -214. 2. Yarnall KHS. AJPH 2003; 43: 635 -641. 3. Bodenheimer T. NEJM 2006: 355: 861 -864.

TODAY’S CARE MEDICAL HOME CARE My patients are those who make appointments to see TODAY’S CARE MEDICAL HOME CARE My patients are those who make appointments to see me Our patients are those who are registered in our medical home Patients’ chief complaints or reasons for visit determines care We systematically assess all our patients’ health needs to plan care Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet patient needs without visits Care varies by scheduled time and memory or skill of the doctor Care is standardized according to evidence-based guidelines Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care I know I deliver high quality care because I’m well trained We measure our quality and make rapid changes to improve it Acute care is delivered in the next available appointment and walk-ins Acute care is delivered by open access and non-visit contacts It’s up to the patient to tell us what happened to them We track tests & consultations, and follow-up after ED & hospital Clinic operations center on meeting the doctor’s needs A multidisciplinary team works at the top of our licenses to serve patients Slide from Daniel Duffy, MD School of Community Medicine Tulsa Oklahoma

Medical Home: NCQA Definition o NCQA definition of a medical home: n Each patient Medical Home: NCQA Definition o NCQA definition of a medical home: n Each patient has an ongoing relationship with a personal physician who leads a team that takes collective responsibility for patient care. n The physician-led care team is responsible for providing all the patient’s health care needs and, when needed, arranges for appropriate care with other qualified physicians

Medical Home: NCQA cont. o PPC-PCMH has 3 levels of recognition and measures: n Medical Home: NCQA cont. o PPC-PCMH has 3 levels of recognition and measures: n Access/communication Patient tracking/registry functions Care management Patient self-management support E-prescribing Test/referral tracking Performance reporting n “Advanced” electronic communication n n n

PCMH: Integral to the Residency Care Experience o o o Make it a PRIORITY PCMH: Integral to the Residency Care Experience o o o Make it a PRIORITY Part of the Culture Taught at Every Venue n n n o Orientation Inpatient Outpatient Systems Supporting PCMH

Permanente Medical Groups in California Departments of Family Medicine & Family Medicine Residencies PRACTICE Permanente Medical Groups in California Departments of Family Medicine & Family Medicine Residencies PRACTICE ORGANIZATION o Financial Management o Practice Development o Practice Data o Customer Engagement QUALITY MEASURES o Registries o Referrals o Patient Safety Alerts o Patient Reminders o Care Plan HEALTH INFORMATION TECHNOLOGY o E-prescribing o Population Registry o Clinical Decision Support tools o Connection o Experimental care delivery PATIENT EXPERIENCE o Open/Advance Access scheduling o Patient portal o Patient self management o Communication

Practice Organization Financial Management Budget and forecast management in conjunction with Kaiser Health Plan Practice Organization Financial Management Budget and forecast management in conjunction with Kaiser Health Plan Coding education with certified physician coders Inpatient rounding with utilization managers Drug, Lab and Radiology utilization action teams Practice Development Manager and leadership off-sites/training Department/unit based teams (UBT) SCPMG university New Employee Orientation (NEO) Practice Data Access date: Bonding rate, Adjusted utilization, Leakage reports People Pulse survey: Labor Management Partnership (LMP) Customer Engagement KP Ambassador program

Quality Measures Registries Permanente Online Interactive Network Tools (POINT) Clinical Strategic Goal (CSG) Care Quality Measures Registries Permanente Online Interactive Network Tools (POINT) Clinical Strategic Goal (CSG) Care gaps: granular down to individual/clinic performance Referrals e-Referral and e. Consult Patient Safety Alerts Labs: duplicate future order alert Meds: interaction alert Allergies: built into Health. Connect Practice Reminders Best Practice Alerts Health Maintenance Alerts Care Plan Problem/medication list After Visit Summary: patient information at check-out

Health Information Technology E-prescribing Integrated within Health. Connect and linked to all pharmacies in Health Information Technology E-prescribing Integrated within Health. Connect and linked to all pharmacies in each region (NCAL or SCAL) Formulary substitution alert Weight based dosing built in for certain medications Population Registry Population Care Management (Proactive office encounter) Clinical Decision Support tools On-line clinical library Medication look up directly linked from Health. Connect Clinical practice guidelines built into referral templates PACS/IMIS, Visible light, MUSE – interfaced systems Connection Internet/intranet access in ambulatory and inpatient areas Data extraction via Clarity reports Experimental care delivery Garfield Center Office of the Future

Patient Experience Open/Advance Access scheduling Same day appointments Clinic start on time reporting Access Patient Experience Open/Advance Access scheduling Same day appointments Clinic start on time reporting Access departments – standardization of appointment types Patient portal: KP. org Personal medical records review Patient emails Online appointment direct booking Prescription refill requests Online health information Patient self management KP On-Call Motivational interviewing pilot “DM insulin new start” Group visits Communication Language concordance program Onsite interpreter Spanish/Chinese/Vietnamese Centers of excellence Patient satisfaction surveys (ASQ, METEOR, MAPPS/MPS)

USE OF PATIENT-CENTERED MEDICAL HOME COMPONENTS BY FAMILY PHYSICIANS Electronic medical records 49. 2% USE OF PATIENT-CENTERED MEDICAL HOME COMPONENTS BY FAMILY PHYSICIANS Electronic medical records 49. 2% Chronic disease management 46. 8% Extended office hours 42. 4% Web-based information for patients 35. 7% E-prescribing 31. 7% Open-access scheduling 28. 9% Team approach 22. 1% E-mail with patients 21. 0% Registries or patient tracking systems 20. 7% Performance management of processes or clinical recommendations 20. 4% Electronic performance measurement reporting 20. 0% Self-care management support 13. 4% Outcomes analyses 11. 3% Online appointments 10. 2% Patient population management 9. 8% Source: AAFP Practice Profile I Survey, July 2008.

Meaningful Use: An Overview From 36, 000 Feet Meaningful Use: An Overview From 36, 000 Feet

MU Objectives Overview o o 15 core objectives – providers, 14 – hospitals 10 MU Objectives Overview o o 15 core objectives – providers, 14 – hospitals 10 menu objectives Most objectives have provider and hospital objectives Functionality / workflow used to fulfill objectives must be certified

CORE REQUIREMENTS o o Medication orders submitted electronic (Computer Provided Order Entry – CPOE) CORE REQUIREMENTS o o Medication orders submitted electronic (Computer Provided Order Entry – CPOE) Implement drug/drug and allergy/drug check o 30% of all patients (lab and radiology in stage 2 – threshold then 60%) o Enabled

CORE REQUIREMENTS o o o Generate/transmit prescriptions electronically Maintain up to date problem list CORE REQUIREMENTS o o o Generate/transmit prescriptions electronically Maintain up to date problem list Maintain active medication list o More than 40% of patients o More than 80% of all patients (at least one dx or “none”) More than 80% of all patients (At least one entry) o

CORE REQUIREMENTS o Maintain active medication allergy list o Smoking status – over 13 CORE REQUIREMENTS o Maintain active medication allergy list o Smoking status – over 13 y/o - structured field o More than 80% of patients o More than 50% of patients

CORE REQUIREMENTS o Implement one designed decision support rule n o Track compliance Report CORE REQUIREMENTS o Implement one designed decision support rule n o Track compliance Report ambulatory clinical quality measure to CMS o Track compliance

CORE REQUIREMENTS o Demographics recorded – structured n n n o n n More CORE REQUIREMENTS o Demographics recorded – structured n n n o n n More than 50% o More than 50% Preferred language Gender Race Ethnicity Date of birth Record vital signs n o Height – structured Weight – structured BP – structured BMI Growth Charts 2 -20 o Including BMI

CORE REQUIREMENTS o Provide patients with electronic copy of health information upon request n CORE REQUIREMENTS o Provide patients with electronic copy of health information upon request n n o o More than 50% within 3 business days o More than 50% with 5 business days Diagnostic test results Problem list Medication allergies Provide clinical summaries for patients for each office visit

CORE REQUIREMENTS o o Capability to exchange key clinical information among providers electronically Privacy CORE REQUIREMENTS o o Capability to exchange key clinical information among providers electronically Privacy and Security Protect electronic health information o One test and confirmation o Security risk analysis

Care Gap Reports Care Gap Reports

Outcomes Outcomes

Outcomes o o Patient care and safety improvements Access improvements Improved patient satisfaction Cost Outcomes o o Patient care and safety improvements Access improvements Improved patient satisfaction Cost savings

Pugno’s Pearls for a Positive Perspective o o Behave in an optimistic manner and Pugno’s Pearls for a Positive Perspective o o Behave in an optimistic manner and you will indeed feel optimistic Avoid negative people – they are energy vampires and “suck energy” Learn something positive (and useful) from every failure Look at the avocado – God has a sense of humor. It’s ok to laugh at yourself once in awhile n Pugno. JABFM. January 2009

Pugno’s Pearls for a Positive Perspective o o o Try always to do what’s Pugno’s Pearls for a Positive Perspective o o o Try always to do what’s right, not just what’s expedient. Even if you fail – you were on the “high road” Always tell the truth – it’s much easier than remembering the lie Remember – success favors the well prepared. “Life is filled with golden opportunities, carefully disguised as irresolvable problems”

It’s the Relationship! We Make a Difference!!! Photo used with permission It’s the Relationship! We Make a Difference!!! Photo used with permission

The Medical Home in Residency: Group Health Family Medicine Residency Seattle Carl Morris, MD The Medical Home in Residency: Group Health Family Medicine Residency Seattle Carl Morris, MD - Associate Program Director

Outline o o o Group Health’s Medical Home Group Health Residency Medical Home Outcomes Outline o o o Group Health’s Medical Home Group Health Residency Medical Home Outcomes Next steps Discussion

Group Health – Introduction o o Integrated staff model HMO in Washington and western Group Health – Introduction o o Integrated staff model HMO in Washington and western Idaho established in the 1940 s > 600, 000 patients 26 primary care clinics: 81% FPs, 4% internists, 15% pediatricians 4 specialty clinics, 6 UC/ER, 7 hospitals (contracted) 36

The Group Health Medical Home: Background o 2002 n n n Chronic Disease registries The Group Health Medical Home: Background o 2002 n n n Chronic Disease registries Case management Quality reporting Limited EMR Production-based incentives 37

The Group Health Medical Home: Background o 2002 -2006 a series of reforms including The Group Health Medical Home: Background o 2002 -2006 a series of reforms including n n Same day appointing (open access) Implementation of a new EMR (EPIC) Online patient access (email to provider, labs, record) Added to existing provider/staff template 38

The Group Health Medical Home: Background o Results n n n Improved patient access/satisfaction The Group Health Medical Home: Background o Results n n n Improved patient access/satisfaction Increased MD workload Decreased MD satisfaction Increased utilization/cost: ER, specialty, hospital Reductions in quality of care 39

Houston, we have a problem 40 Houston, we have a problem 40

The Group Health Medical Home: Problems and a Proposal o The Problems: n n The Group Health Medical Home: Problems and a Proposal o The Problems: n n o Physicians were burned out Many planned early retirements It was difficult to find new recruits Costs up, quality down Proposal from the Medical Director: n Medical Home Pilot 41

The Group Health Medical Home: Core Principles o o o Relationship to PCP is The Group Health Medical Home: Core Principles o o o Relationship to PCP is core Physician leads the clinical care Care is comprehensive Patient-centered access: 24/7, electronic Align clinical and business systems 42

The Group Health Medical Home Changes: o o Structural Point of care Patient outreach The Group Health Medical Home Changes: o o Structural Point of care Patient outreach Management structure/philosophy 43

The Group Health Medical Home o Structural changes n n Decrease patient panels (from The Group Health Medical Home o Structural changes n n Decrease patient panels (from 2300 to 1800) Longer visits (30 not 20 min) Dedicated “desktop medicine time” Automated phone call routing 44

The New Schedule The New Schedule

The Group Health Medical Home o Point of care changes n n n Promotion The Group Health Medical Home o Point of care changes n n n Promotion of web portal functions (pharmacy refills, secure messaging, medical information, online appointing) Pre-visit chart review After visit summaries at end of visit 46

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

Pre-visit Work: o Done Prior to the Visit by the MA Pre-visit Work: o Done Prior to the Visit by the MA

The Group Health Medical Home o Patient outreach changes n New patient outreach n The Group Health Medical Home o Patient outreach changes n New patient outreach n Chronic disease medication n Birthday reminder care letters n Outreach using deficiency reports (for both chronic conditions and health maintenance) 49

The Group Health Medical Home: Pilot Project o Management changes n Daily team huddles The Group Health Medical Home: Pilot Project o Management changes n Daily team huddles n Visual reporting systems to track changes n Rapid process improvement cycles n Lean management philosophy 50

The Huddle o Communicate clinical process changes o Review access and performance targets o The Huddle o Communicate clinical process changes o Review access and performance targets o Review quality measures

Daily Tracking: Visual Report on Access Daily Tracking: Visual Report on Access

Weekly Report: Visual Report on Clinic Visits, Phone and e-Visits Weekly Report: Visual Report on Clinic Visits, Phone and e-Visits

The Group Health Medical Home: Outcome – Year One o o Cost neutral Improved The Group Health Medical Home: Outcome – Year One o o Cost neutral Improved patient satisfaction Improved quality of care (HEDIS) measures Improved provider satisfaction Reid RJ, Fishman PA, Yu et al. Am J Manag. Care 2009: 15(90): e 71 -e 87 54

The Group Health Medical Home: Outcome – Year Two o Continued improvement in n The Group Health Medical Home: Outcome – Year Two o Continued improvement in n o Patient satisfaction Quality Physician satisfaction (decrease in burnout) Cost savings n n 6% fewer hospitalizations 29% fewer ER visits Reid et al. The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, and Less Burnout for Providers. Health Affairs. 2010; 29(5): 835 -843

The Residency Medical Home The Residency Medical Home

GH Residency Medical Home How does a residency clinic differ? o Dual Mission of GH Residency Medical Home How does a residency clinic differ? o Dual Mission of Teaching and Patient Care o Training Residents o Complexity working in a large organization o Rules and regulations o Inefficiencies 57

GH Residency Medical Home: Implementation Training Residents o Introduction to concepts of the medical GH Residency Medical Home: Implementation Training Residents o Introduction to concepts of the medical home early and often (didactics, business meetings) o Increased involvement of support staff as teachers o Early 1: 1 chairsides with faculty 58

GH Residency Medical Home: Implementation Training Residents o Acknowledgement of need to prepare for GH Residency Medical Home: Implementation Training Residents o Acknowledgement of need to prepare for a new model of care: virtual visits are a part of training! n n o Training for phone visit and electronic visit content and documentation Process for evaluation and review of secure messages Regular time to review guidelines and registry data with planned outreach 59

GH Residency Medical Home: Implementation Multiple providers o Huddles at the beginning of each GH Residency Medical Home: Implementation Multiple providers o Huddles at the beginning of each clinic o Involve support staff ACTIVELY in all change o Identify teams (providers and support staff) o Inbasket coverage: Teams cover, but much electronic work is done from off site by the primary care provider. 60

GH Residency Medical Home: Implementation Rules and Regulations o RRC innovation proposal: credit for GH Residency Medical Home: Implementation Rules and Regulations o RRC innovation proposal: credit for phone and secure messages (3 visits worth one face-to-face. 1400 visits, 750 virtual visits over 3 years) o GH driven: Clinic template changes 61

The New Schedule The New Schedule

GH Residency Medical Home: Outcomes o o Quality measures Patient satisfaction RRC Innovation Proposal GH Residency Medical Home: Outcomes o o Quality measures Patient satisfaction RRC Innovation Proposal accepted Paradigm shift in training 63

GH Residency Medical Home: Outcomes: Quality Measures o HEDIS scores n One year pre GH Residency Medical Home: Outcomes: Quality Measures o HEDIS scores n One year pre and post results n Remarkable changes in preventive and chronic disease measures 64

2009 -2010 HEDIS Measures Mar 09 Mar 10 Trend ABX Adult Acute Bronchitis 65. 2009 -2010 HEDIS Measures Mar 09 Mar 10 Trend ABX Adult Acute Bronchitis 65. 4% 36. 4% 29. 0% Well-Child 3 -6 YO 50. 0% 75. 0% 25. 0% Screen: Colorectal Cancer (NEW) 38. 3% 60. 1% 21. 8% Postpartum Care 56. 7% 78. 2% 21. 5% DM: Hb. A 1 c>9. 0 51. 5% 32. 5% 19. 0% ASA: Ace for CAD 63. 0% 75. 6% 12. 6% DM: Hb. A 1 c Test 78. 8% 88. 3% 9. 5% Well-Care Adolescent 27. 3% 36. 1% 8. 8% ASA: Ace for DM 68. 4% 75. 4% 6. 9% IET: Engagement 9. 8% 16. 7% 6. 9% Screen: Breast Cancer Total 50. 3% 56. 1% 5. 9% DM: BP <140/90 54. 5% 59. 7% 5. 2% CAD: Chol Mgt-LDL Screen 85. 7% 90. 0% 4. 3% DM: LDL Screen 72. 7% 76. 6% 3. 9% ASA: Statin for CAD 77. 8% 80. 5% 2. 7% Prenatal Care 83. 3% 85. 9% 2. 6% High Blood Pressure 50. 6% 52. 4% 1. 8% Screen: Cervical Cancer 75. 5% 76. 9% 1. 3% Asthma Appropriate Meds 83. 3% 84. 6% 1. 3%

GH Residency Medical Home: Outcomes: Patient Satisfaction o Patient Satisfaction n One year pre GH Residency Medical Home: Outcomes: Patient Satisfaction o Patient Satisfaction n One year pre and post results n Improvement in all categories 69

GH Residency Medical Home: Next Steps o o o Curriculum revision n More consistent GH Residency Medical Home: Next Steps o o o Curriculum revision n More consistent time in clinic n More explicit training in e-visits Chronic Disease Management (TIC sessions) Continuous improvement n Use of data 71

Paradigm Shift in Training o Post-Flexnerian change n n n From science to systems Paradigm Shift in Training o Post-Flexnerian change n n n From science to systems Reprioritize core of training – clinic first Continuity clinic = center of excellence

Paradigm Shift in Training o System reform n Align incentives o o o Quality Paradigm Shift in Training o System reform n Align incentives o o o Quality not quantity Outpatient continuity System and science

Paradigm Shift in Training o System reform n GME reform o o n RRC Paradigm Shift in Training o System reform n GME reform o o n RRC – measuring continuity Payment – aligned with training Primary care training re-focused o o o Centers of excellence Leaders of innovation Graduates ready to transform primary care

Discussion 75 Discussion 75