Project Summary:

Washington Patient-Centered Medical Home Collaborative

Pat Justis, MA Department of Health

Objectives

• Briefly summarize the project goals, structure ,activities, and participants

• Provide an initial look at results• Provide information related to

accreditation and the national work on medical home

• Discuss key lessons

3

DOH

• Seven collaboratives since 1999• Diabetes• Later hypertension, asthma, youth obesity,

medical home• Partners

– Qualis Health– Improving Chronic Illness Care (ICIC) funded by Robert Wood

Johnson Foundation.– Acumentra Health, University of WA– Washington Academy of Family Physicians

Washington Patient-Centered Medical Home Collaborative

• 33 teams began, 31 finished.• 24 months, 2009-2011• Five learning sessions/ 8 full days• Five plus site visits by Quality

Improvement Coach • Monthly webinars/e- news bulletins• Reporting of data and narrative reports• Ongoing support by e-mail/phone/website

What are we trying to accomplish?

The Mission

To implement medical homes in a variety of primary care clinics and improve the care of patients/families using the collaborative methodology.

Goals

• Develop an implementation model for primary care medical home which:– Improves health outcomes for patients – Improves the patient and family’s experience

of care – Improves primary care team satisfaction

• Examine overall health care utilization and costs impacted by medical home implementation.

The “other” medical home legislation-2009Health Care Authority/Puget Sound Health Alliance

• Separate but “connected” payer demonstration with anti-trust safe harbor.

• 12 practice sites/8 organizations• 9 of 31 Collaborative teams participating• Official start-May 2, 2011• 26,000 attributed patients• Now collecting data on first two months.

Total number of providers, all Collaborative sites=755 providers

11

12

9

Number of sites that have providers in the des-ignated number range

Collaborative participants

5 or fewer providers 6 to 20 providers 21+ providers

Population density surrounding participating clinics

13

11

3

6

Participating clinics by population density

Urban 50,000 +

Sub-Urban 30-49% commuter flow to Urban

Large Rural to 10,001 to 49,000

Small town/isolated rural up to 10,000

Patients at participating sites by age group

Total estimated patients, all ages= 738,111

under 18 adults (includes over age 65) estimated over age 650

100,000

200,000

300,000

400,000

500,000

600,000

700,000

129,316

608,795

64,916

Estimated patients in WPCMHC by age

age categories

estimated number of pa-tients

Early evidence suggests…

• Patient satisfaction improves.• Provider satisfaction improves.• Burn-out decreases.• Avoidable emergency room visits

decrease.• Clinical outcomes improve.• Cost savings or neutralizes cost increase.

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Measure synopsis

• Patient experience-flat in aggregate, individual clinics made significant gains

• Provider/team satisfaction• Clinical measures-many clinics have

significant progress– Prevention– Diabetes

• Medical Home Index-improved steadily

MHI Overall Score Domain 1: Organiza-tional Capacity

Domain 2: Chronic Condition Man-

agement

Domain 3: Care Co-ordination

Domain 4: Com-munity Outreach

Domain 5: Data Management

Domain 6: Quality Improvement/Change

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

4.17 4.10 3.93 3.983.63

5.81

4.59

5.25 5.234.95 4.98

4.50

6.74

6.22

5.69 5.58 5.60 5.54

5.04

6.83

6.33

Change in Medical Homeness Over Time

September 2009 September 2010 September 2011

Ave

rage

sco

re fo

r all

clin

ics

com

bine

d

Medical Home Index

Relationships between measures/ clinic characteristics

• To be explored in final analysis– Do clinic traits correlate with any particular

findings?– Are there any connections between the

various measures, for example do high medical home index scores associate with improved clinical outcomes?

Medical Home Indexheadlines

• Some clinics may overestimate their own scores, others may be too self-critical.– The scores between clinics are not a useful

comparison.• Use as a tool to stimulate understanding,

continual self-assessment and instigate quality improvement.

The tools

• Medical Home Index-adult and peds (MHI) (Center for Medical Home Improvement)

• Patient-Centered Medical Home Assessment (PCMH-A) ( Safety Net Medical Home Initiative)

• Medical Home Implementation Quotient (MHIQ) ( Transform Med-AAFP profit arm)

• http://www.urban.org/uploadedpdf/412338-patient-centered-medical-home-rec-tools.pdf

The accreditation quandary

• Newly revised NCQA PCMH standards• Joint Commission has new voluntary

standards for “primary care homes.”• States with state legislated accreditation:

Oregon, Minnesota• Tools : Medical Home Index, Transform

Med, The Patient-Centered Medical Home Assessment , and more.

States with the most activity; rapidly spreading

• Colorado• Vermont• New Hampshire• Michigan• Maine• New York• North Carolina• North Dakota• Minnesota

• Ohio• Texas• Arizona• Louisiana• Pennsylvania• Rhode Island• Georgia• Tennessee• Illinois

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Health Home Bill 5394 (2011)

“To promote the adoption of primary care health homes for children and adults and, within them advance the practice

of chronic care management to improve health

outcomes and reduce unnecessary costs. “

Health Home Bill 5394 (2011)

• Payers must offer incentives for quality and adoption of health home, care of chronic disease to providers.

• Affects all plans under HCA, including PEBB plans

• Payment to support providers to participate in training and technical assistance.

DOH role with 5394

• Training and technical assistance for providers of primary care;

• Related to evidence based high quality preventive and chronic disease care

• In collaboration with Health Care Authority

Section 2703 Affordable care act

• 5% of Medicaid clients responsible for 50% of costs.

• Scale up and spread existing demonstrations.

• Team based care coordination with behavioral health integration.

• Remove funding silo barriers.

Ongoing challenges

• Accreditation vs. quality measures• Payment reform: risk, patient choice, gains

sharing, transition between FFS and bundles and or PMPM

• Solo providers and networks• Payers ability to test models• Transitions :cross-setting improvements

Workforce puzzles

• Scope of practice for medical assistant wildly variable.

• What helps physicians transform leadership to a team facilitation style?

• Better integration of pharmacists.• More intentional change to role of RN• Shortage of primary care providers/nurses

The Transform Med Demonstration lessons

• Clinic autonomy• Adaptive reserve• Transformative level of change• Changes are linked and interdependent

Lessons learned

• Every funder wants a pet measure; this places an undesirable burden; must find root drivers, proxies, alignment etc.

• Data must be in the hands of the team; and organizations vary in this ability.

• EMR’s vary widely in registry like functions for population management

Health literacy

A large, fundamental

paradigm shift related to who

has the responsibility to

create understanding.

Relationships are the center

• Providers and teams• Teams and other teams• Provider/Team and patients/families• Across care settings and transitions in

care.• Continuity of relationship is patient-

centered and must trump convenience and provider schedule preferences.

Lessons

• Teamwork is a learned skill, not an innate ability.

• Facilitative leadership comes easier to some than others but begins with willingness to develop trust.

What is ahead?

• Age specific/• Peds involvement• Community based

and across settings• Rural• Behavioral health• Prevention of chronic

conditions

• Scalable; more teams, more open enrollment.

• Testing face-face “dosage”

• More linkage between education and coaching.

• Cross-setting improvements