Medical Home Model: Patient Centered Care
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Transcript of Medical Home Model: Patient Centered Care
1 | Group Health Solutions for Transforming Care
Michael Erikson, MSW, vice president, Primary Care Services
Robert Reid MD, PhD, MPH, associate medical director, Health Services Research & Knowledge Translation
Barbara Trehearne PhD, RN, vice president, Clinical Excellence, Quality, and Nursing Practice
Claire Trescott, MD, medical director, Primary Care Services
The Medical Home Model: Patient Centered Care
2 | Group Health Solutions for Transforming Care
The Burning Platform of Primary Care
• Access to primary care difficult for many, particularly disadvantaged.
• Quality of remains mediocre with many gaps.
• Payment systems are antiquated. Many functions are unrewarded.
• Evidence-base has become unmanageable for individual physicians.
• Primary care is an unattractive career choice. Burnout common.
3 | Group Health Solutions for Transforming Care
Medical Home Design Principles
✔
✔✔
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✔ The relationship between the clinician & patient is at our core. The entire delivery system will reorient to promote & sustain.
The primary care clinician will be a leader of the clinical team, responsible for coordination of services, and together with patients will create collaborative care plans.
Care will be proactive and comprehensive. Patients will be actively informed and encouraged to participate.
Access will be centered on patients needs, be available by various modes, and maximize the use of technology.
Our clinical and business systems are aligned to achieve the most efficient, satisfying and effective experiences.
4 | Group Health Solutions for Transforming Care
Informed,ActivatedPatient
ProductiveInteractions
Prepared,Proactive
Practice Team
DeliverySystemDesign
Decision
Support
ClinicalInformation
Systems
Self-Management
Support
Health SystemCommunity Resources &
Policies
Health Care Organization
Improved Outcomes
The Chronic Care Model (CCM)
(Wagner EH et al, Managed Care Quarterly, 1999.7(3) 56-66)
5 | Group Health Solutions for Transforming Care
Medical Home: Change Components
• Calls redirected to care teams• Secure e-mail • Phone encounters• Pre-visit chart review• Collaborative care plans• EHR best practice alerts• EHR prevention reminders• Defined team roles
Point-of-care changes• ED & urgent care visits• Hospital discharges• Quality deficiency reports• e-health risk assessment• Birthday reminder letters• Medication management• New patients
Patient-centered outreach
• Team huddles• Visual display systems• PDCA improvement cycles• Salary only MD compensation
Management & payment
PCMH Model
6 | Group Health Solutions for Transforming Care
Group Health Medical Home Staffing Model
Increased Staffing (per 10,000 enrollees)
Physician (panels 2500 to 1800) 5.6 FTE 17%
PA/NP 1.5 FTE 70%
RN 1.2 FTE (no change)
LPN 2.0 FTE 65%
MA 5.6 FTE (no change)
Pharmacist 1.0 FTE 100%
7 | Group Health Solutions for Transforming Care
Medical Home 1 & 2 Year Pilot Outcomes
Year 1 Year 2
Group Health Research Institute
QUALITY (HEDIS)
Year 1: Rate of rise, 2x that of control clinics
Year 2: Rate of rise continued to be 20-30% greater in 3 of 4 composites
PATIENT/STAFF SATISFACTION
Year 1: Patient satisfaction – 5% increase in patient activation/goal setting;
Practioners - *substantially less burn-out with significantly reduced emotional exhaustion & depersonalization
Year 2: Scores continued to improve at Medical Home; controls were slightly worse
ED/UC UTILIZATION
Year 1: 29% fewer ER visits, 11% fewer preventable hospitalizations, 6% fewer but longer in-person visits
Year 2: Significant changes persisted
COST
Year 1: Cost is neutral
Year 2: Overall patient care costs lower at Medical Home (~$10 PMPM)
Challenges Overcome
9 | Group Health Solutions for Transforming Care
• All Work Processes are designed by staff who do the work
• Representatives from diverse clinics contribute to design
• Initial designs will be flawed, aim for 50% improvement
• All feedback from frontline staff will be recorded and used to improve processes
Essential Leadership Concepts
10 | Group Health Solutions for Transforming Care
Key Elements: Management System
Links Business plan to front line workAlternative to “execution by wishful thinking”
Shows Performance Gaps Multiple Levels Driver
of Change
Reduce WasteImprove QualityPatients Point
of View
Accountability
Lean Management
System
Metrics and Visual Displays
Value Stream
Redesign
11 | Group Health Solutions for Transforming Care
Our “Secret Sauce” for Spreading Standard Work
• MANAGEMENT BELONGS IN THE CLINICS
• Leaders must understand all standard work
• Leaders round on all standard work daily or weekly
• Processes and outcomes are visible in the clinic
• Where we struggled with implementation it was ALWAYS because of leadership problems
• Work in the clinics is linked to visible data at all levels of management
12 | Group Health Solutions for Transforming Care
Current Innovation: Frontline Improvement Initiative
• Moving from Adaptive Leadership to an Adaptive Workforce
• Designing for a world of continuous change
• Using Lean principles to do structured changes in everyday processes
13 | Group Health Solutions for Transforming Care
Building Teams
• Probably our most difficult leadership challenge
• Co-location does not guarantee teamwork
• Physician’s not necessarily trained to work in teams
• Huddles essential and continue to offer opportunities
• Nursing changes challenging
• Visible Patient Care Boards are effective
14 | Group Health Solutions for Transforming Care
Nursing Boards
15 | Group Health Solutions for Transforming Care
Medical Home: Role of Nursing
• Outpatients require higher level of care
• Increased complexity of care requires higher skill for coordination and chronic disease management
• Skilled RNs can effectively manage chronic illness in partnership with a well developed interdisciplinary team
• Team RNs and Complex Case Managers focus on self management support & increasing motivation to improve adherence to care/medications
• Team based RNs can assess broad spectrum of needs, partner with patient and PCP, develop plan of action, coordinate resources
16 | Group Health Solutions for Transforming Care
Nursing Challenges
• Capacity for managing both acute and chronic populations
• Need to rethink skill development; what do nurses need to know
• Role changes from ‘tradition’ outpatient to patient centered, focus on self management, coordination of care
Transition to the Future Medical Home Model
18 | Group Health Solutions for Transforming Care
Rethinking Medical Centers
Tier 3: Medical Sub-specialties
Tier 2: Eye Care, Occ Health, PT
Tier 1: PC, Pharmacy, Lab, Radiology
TIER 1
TIER 2
TIER 3
19 | Group Health Solutions for Transforming Care
Transformational Thinking
See what’s not there
Reframe
Move
Think about nature
Journalistic Six
Word Association
Change your lens
20 | Group Health Solutions for Transforming Care
Next Evolution of Our Clinical Transformation
Patient-Centered Medical Home
CSS Honors
2010 Achievements
• PDP
• Virtual Visits
• Call Management
21 | Group Health Solutions for Transforming Care
Care & Facility Redesign Opportunities
22 | Group Health Solutions for Transforming Care
What’s Next for Medical Home?
Integrated Care & Facility Design – Using 3P
As an extension to Group Health's medical home practice redesign, we are looking to the next stage to:
• Redesign how the staff optimally interacted with each other and their patients
• Redesign the staffing. Redesign the physical work environment to further optimize our clinical work and patient’s experience
The brick and mortar solutions will focus on:• Standardization of rooms, materials, furniture, equipment• Modular walls and furniture• Sustainability with a focus on mechanical systems• Evidence based design solutions• Integrated Project Delivery Agreements
23 | Group Health Solutions for Transforming Care
Integrated Care & Facility Design – Using 3P
The brick and mortar solutions will focus on:• Increasingly more care is virtual
PhoneE-visitsConsultations between medical-surgical specialties
• Co-design all processes that patients use or touch within a visitCheck-in – business functionClinicalAncillary
• Design those processes around the patient: be patient centeredExample-Bring services to patients-Reduce/eliminate waiting-Can waiting rooms become unnecessary?
• Consider & design all material supply chains to reduce inventory and turn rates
• Design in flexibility, quality while reducing overall facilities costs• Partner with architects, builders differently
What’s Next for Medical Home?