Frank deGruySeptember 12, 2011

Our Healthcare System Is Broken What Distinguishes A High-Quality

System? The Definition of Primary Care Improving Healthcare Services The Principles of Redesign The Particulars of Redesign Sustainability

“Never has a nation spent so much on so few for so little.”

Larry Green

Answer: A foundation of high-quality primary care

“Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, [no matter how measured].

The means by which primary care improves health have been identified….”

Contributions of Primary Care to Health Systems and Health Starfield B, Shi L, Macinko J.

The Milbank Quarterly; 83: 457-502. 2005

Improved health Equity in health care Lower cost

“Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”

 Defining Primary Care: An Interim Report.

Institute of Medicine Committee on the Future of Primary Care.National Academy Press, Washington DC, 1994

“…responsible for providing for all the patient’s health care needs…”

“Care is coordinated and/or integrated across all elements…”

Joint Principles of the Patient Centered Medical Home

American Academy of Family Physicians (AAFP)American Academy of Pediatrics (AAP)American College of Physicians (ACP)

American Osteopathic Association (AOA)

February 2007

Acute Care Chronic Care Preventive Services

Self-management Education Coordination & integration

Mental and Medical Others

Function, not location Fragmentation Financing

11Number of physical symptoms

12

Robert Graham Center, “Why there must be room for mental health in the medical home; NBGH: An Employers’ Guide to Behavioral Health Services

13McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12.Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.

Myopia Psoriasis Hypothyroidism Allergies

Depression Multiple Sclerosis Epilepsy

Chronic Back PainInfertility Crohn’s Disease GERD

Ulcerative Colitis

Sickle Cell Disease

Type I Diabetes

Parkinson’s

Cystic Fibrosis CAD

Chronic Hep B

Osteoporosis Cerebrovascular Dz Hypertension Hyperlipidemia

Asthma CHFSchizophrenia Type II DM

Alzheimer’s Obesity

Bipolar Disorder Addictions

Requirement for behavior change

Moti

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Vision for serving the whole person PCMH as a prototype CMHC’s already ahead in some areas

Care managers Wraparound services Chronic illness management

Behind in others Medical illness and medical system Pace of practice Sharing health information

Culture of change QI Plan-Do-Study-Act (PDSA)

Measurement-based outcomes Team-based care Leadership for change New principles of communication Self-management, groups, peer support External partnerships

Registries Comprehensive personal care plan for all Solid expertise on hand for

Common physical conditions The deep end Health behavior change

Self management Preventive services

Payment reform is an absolute prerequisite

Eliminate fragmentation of payment Commingled funding streams Accountability for all elements of health

Pay for health, not procedures, not visits Pay for quality care Pay for collaboration & coordination Pay patients for healthy living Pay for innovation Reward cost savings