Medical Home and Disease Management: Convergence Synergy National Medical Home Summit, 2009 Jaan...

Medical Home and Disease Management:Convergence Synergy

National Medical Home Summit, 2009

Jaan Sidorov, MD, MHSA – Sidorov Health Solutions

Doug Berkson, MPH – Health Dialog

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 managementMeasurementMedical Neighborhood

Oberservations and Thoughts on Current State of Patient-Centered Medical Home


1. Data Aggregation and Analytics

2. Reach and Engage

4. Measurement 3. Intervention

Integrated Care Management:New Model (Medical Home?)

Traditional Disease Management ModelTraditional Disease Management Model Vendor primarily responsible for all components

Integrated Care Management ModelIntegrated Care Management Model Providers/Practices may take role in any or all components


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


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

Last Name

First Name ID # Age Sex

Chronic Condition(s)

1 2 3 1 2 3 PCP Visits Spec. Visits Admits Total Inpatient Outpatient Rx

Risk Scores Quality Gaps Utilization History Cost History (by bucket)


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


3. InterventionA 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


4. Measurement: Quality alone is insufficient.


4. Measurement - it’s not just about what happens in primary care…

Primary CarePrimary 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


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 Variationin

Quality – Preference - Efficiency


4. Measurement – from the Medical Home to the Medical Neighborhood

Medical Home-----------------------

Coordinated Primary Care

Medical Home-----------------------

Coordinated Primary Care





Hospital A$7,244

Hospital A$7,244

• High Quality• Patient preferences • Efficient care• No more than necessary

High Performing Community


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


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


Questions?

Medical Home and Disease Management: Convergence Synergy National Medical Home Summit, 2009 Jaan...

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